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Positive Behaviour Support is an applied behaviour analytic system of support that is utilised in schools and in residential care settings for children and adults with disabilities who engage in challenging behaviour. Implementation fidelity depends on appropriate staff training and organisational behaviour management. A systematic literature review is reported that evaluated the evidence in relation to change in staff and service user behaviour and the impact of organisational behaviour management systems on effectiveness, generalization, and maintenance of these outcomes. Nine relevant articles were identified and analysed according to (1) the demographics of staff and residents and methods of staff training; (2) organisational behaviour management systems; (3) staff and service-user behavioural outcome measures; and (4) the methodological quality of the study. A combination of antecedent and consequence-based training strategies was used in the studies. Eight studies reported on the organisational behaviour management systems that were used, with five reporting on the responsibility of trainees to transfer their training to their untrained teams (pyramidal training). Although the studies reported on staff behaviour change following the training, only one of the studies reported significant increases of service user quality of life as a result of staff training and only two studies provided adequate methodological strength.

Purpose This paper aims to provide a commentary on the article “Teaching behavioural expectations to secondary age students with intellectual disabilities attending a special school”. Design/methodology/approach The impact on teachers who deal with high levels of behaviours that challenge is explored. Findings The article highlights the importance of proactive, preventative strategies for behaviour management and the need for staff training and support. Originality/value Teachers working with pupils who engage in high levels of behaviours that challenge need training and support.

Purpose School-wide positive behaviour support (SWPBS) is a proactive behavioural support system that fosters behaviour change in individuals in a school setting. This article aims to present a case example of teaching and reinforcing behavioural expectations in a special school. Design/methodology/approach This case study reflects different steps and materials used before and during the intervention in a special education school with 61 secondary students with intellectual disabilities. An AB design (A – baseline; B – intervention) was used to collect and analyze data. Findings Results suggest that teaching behavioural expectations as a universal measure may be feasible and positively impact school climate. Suggestions and recommendations for implementing SWPBS within a school are provided. Originality/value This case study provides a step-by-step guide illustrating the process of teaching and reinforcing behavioural playground expectations to young adults with intellectual disabilities attending a special school.

Purpose A biopsychosocial case formulation is an important tool for understanding complexity and guiding treatment for people with intellectual disabilities. It has been suggested that formulation meetings develop staff understanding of individuals they support. This study aims to explore the change processes that occur as a result of professional team formulation meetings, and the mechanisms that facilitate and hinder these events. Design/methodology/approach Eight clinicians who took part in multi-disciplinary team-based formulations in an inpatient mental health service for adults with intellectual disabilities were interviewed. Interviews were examined using thematic analysis. Findings The key themes identified were: “gaining information”, “altered thoughts” and “focused goals”. These themes were supported by “collaborative working” and “time for reflection” and were hindered by “poor communication and interaction” and inconsistent “staff attendance”. Originality/value Multi-disciplinary team formulation meetings may have a number of change processes that affect staff knowledge and perception of the people that they support. The facilitation of these processes should be a focus for further development.

Purpose Research into culture within intellectual disability services, has predominantly focussed on small group homes in Australia. The current investigation aimed to explore the transferability of the dimensions of culture identified in the literature, to a residential Intellectual Disability service in the UK. The purpose of this study was to better understand the impact of informal culture upon the behaviour of direct care staff, particularly around managing behaviour that challenges. Design/methodology/approach Semi-structured interviews were conducted with direct care staff. Interview transcripts were analysed thematically using template analysis. Findings Themes regarding leadership, perceptions of managers, team functioning, and relationships between direct care staff and service users, were identified, corroborating the existing literature. Additional themes relating to being aware of the risks posed by service users, and the emotional impact of behaviour that challenges, also emerged. Originality/value To the best of the authors’ knowledge, this is the first qualitative study to explore informal culture within a community residential Intellectual Disability service in the UK.

Behaviour support plans (BSPs), if accurately implemented, have been found to increase skills and decrease challenging behaviour of individuals with intellectual and developmental disabilities. Training is essential for staff to acquire the skills necessary for accurate implementation. The aim of this systematic literature review was to evaluate procedures used to train staff in Positive Behaviour Support (PBS), on both knowledge of PBS and implementation of BSPs. Systematic searches of 4 databases identified 18 studies as meeting criteria. Findings indicate that description alone was not consistently effective in increasing knowledge and should be used in combination with other training strategies. Staff’s implementation of BSPs were increased by different combinations of the following training components: description, feedback, modelling, role-play, monitory incentive, and escape contingency. To identify evidenced based practice when training staff on BSPs, it is necessary to evaluate active and feasible training components from current training models.

Purpose Review of antipsychotic prescribing practices, rationale and follow-up using an internationally standardized audit can be an effective tool to encourage and monitor best practices. The purpose of this study is to audit the current prescribing pattern for people with intellectual disabilities and challenging behaviours in Qatar. Design/methodology/approach This study was based on the challenging behaviour management guidelines recommended by the Royal College of Psychiatrists. All current electronic medical records in the Mental Health Service-Hamad Medical Corporation were examined to identify patients with intellectual disabilities who received antipsychotics for challenging behaviour. Demographic variables, such as age, sex and nationality, were collected. In addition, details of psychiatric diagnoses, prescribed psychotropic medications and diagnoses of epilepsy were also collected. For patients who were prescribed antipsychotic medication, the clinical rationale for such medication was collected along with evidence of side effect monitoring to allow performance against the audit standards to be measured. Findings This is the first audit on prescribing practices in people with intellectual disability and challenging behaviour in the state of Qatar. The results of this study regarding the pattern of prescribing practices for patients with intellectual disability and challenging behaviour reflect the limitation in knowledge and experience among non-specialist practitioners within mental health service. The result may be helpful to support the development of specialist service provision to improve the care for such vulnerable group. The result may also help other medical centres and clinicians by providing an improved understanding of possible deviations from the best medical practices. Originality/value This is the first audit on prescribing practices in people with intellectual disability and challenging behaviour in the state of Qatar. The study is also noteworthy as, to the best of the authors’ knowledge, it is one of only a few studies on antipsychotic prescribing for patients with intellectual disability and challenging behaviour in the Middle East; therefore, it will be useful in raising awareness and promoting the best practices in the Middle East region. This study is also among the first few studies that were designed based on the four audit standards by the Royal College of Psychiatrists in this area.

Background Nearly 60,000 people applied for asylum in the Netherland in 2015, confronting the governmental structures and services with great administrative, logistical and service provision challenges. Refugee children’s psychosocial needs and wellbeing are often overlooked, and post-migration support is of pivotal importance. Methods An easy accessible movement–based psychosocial intervention, called TeamUp, was developed for children aged 6–17 living in refugee reception centres. A mixed-method process evaluation was conducted of (1) implementation process, assessing attendance (n = 2183 children, and n = 209 children); (2) implementation quality, using structured observations at two time points to evaluate facilitator’s (2a) individual-level fidelity (n = 81 facilitators); (2b) team-level fidelity (n = 22 teams); (2c) facilitators’ competencies (n = 81); (2d) trainee perceived self-efficacy pre-post training (n = 73); and (3) perceptions on implementation and outcomes, employing a survey (n = 99), focus group discussions and key informant interviews with children (n = 94), facilitators (n = 24) and reception centre staff (n = 10). Results Attendance lists showed a mean of 8.5 children per session, and children attending 31.3% of sessions. Structured observations demonstrated 49.2% and 58.2% individual-level fidelity, 72.5% and 73.0% team-level fidelity, and 82.9% and 88.4% adequacy in competencies, each at T1 and T2 respectively. The main reported challenges included managing children’s energy regulation (e.g. offering settling moments) and challenging behaviour. Training participation significantly improved perceived self-efficacy for trainees. The facilitator survey demonstrated on average, high satisfaction and self-efficacy, low experienced burden, and high perceived capacity-building support. Qualitatively, TeamUp was positively perceived by all stakeholders and was regarded as contributing to children’s psychosocial outcomes. Conclusion (1) Attendance and group size were lower than expected. (2) The intervention’s facilitator fidelity ranged from moderate to adequate—exhibiting a need for specific fidelity and capacity strengthening—while facilitator competencies were high. Trainee’s perceived self-efficacy improved significantly following a 2-day training. (3) Facilitators expressed high levels of satisfaction, self-efficacy and support, and low burden. The intervention was positively perceived by all stakeholders and to have a positive impact on children’s psychosocial learning and wellbeing.

Purpose The purpose of this paper is to outline the development and piloting of a training intervention for social care staff that uses a capable environments framework to improve the quality of staff support. Design/methodology/approach A single case study was used to evaluate changes in the quality of staff support and in levels of engagement and challenging behaviour for one of the individuals supported. Findings The case study demonstrates the usefulness of the capable environments framework as a model for training and development of support planning. Staff provided more positive interaction and support to the individual, who displayed increased participation in activities and reductions in the occurrence and episodic severity of challenging behaviour. Originality/value Capable environments is a systematic, theoretically-driven approach, which is focussed on the quality of support design and provision for people with intellectual disability. The use of such a framework as an intervention assists staff in the provision of effective personalised supports, a foundation for positive behaviour support.

Purpose This paper aims to present a conceptual viewpoint highlighting the utility of active support in implementing capable environments and to extend this by presenting a three-tiered preventative model of positive behavioural support (PBS) in UK health and social care. Design/methodology/approach Provision of a commentary on “Building capable environments using practice leadership” by Linda Hume, Nadia Khan and Martin Reilly. Findings Capable environments and active support should be key, universal and essential PBS tier one supports in UK health and social care. Training staff in Active Support and developing practice leadership help implement capable environments. Originality/value The three-tiered PBS model was recently proposed by Leitch et al. (2020) and is worthy of further debate and refinement with the involvement of stakeholders. It has several practical implications including refocussing efforts on early intervention to get tier one supports implemented effectively in recognition that PBS is much wider than intense tier three supports. It could reinforce and motivate existing providers of quality support and indicate where and how other providers can commence the process of implementing PBS. Future research could consider the effectiveness of applying implementation science to the field of learning disabilities and PBS in particular.

Purpose This paper aims to improve community care for people with intellectual disabilities (ID) and/or autism. Lack of coordination between agencies leads to children and young people with the most complex needs falling between services. The North West Operational Delivery Network (ODN) for learning disability and autism set out to develop a model of care for mental health services for children and young people with ID and/or autism in North West England that would improve coordination between services and lead to better community care. Design/methodology/approach The ODN held a series of good practice events and consultations with stakeholders in North West England to look at gaps in service provision, national guidelines and agree on a pathway for services. Findings The ODN decided to use the THRIVE framework as the basis for a specific model of care. Interventions were mapped against the THRIVE groupings, including pathways and team specifications for assessment and support for children with autism, and models for child and adolescent mental health service support for ID and/or autism, for keeping children and young people with behaviour that challenges in the community and transition. Originality/value This model aims to provide the North West England region with a clear multi-agency approach for supporting the needs of this population and supports multi-agency commissioning, gap analysis, earlier intervention and improving health outcomes for this population.

Background: Person-centred care (PCC) is synonymous with best practice in the care of persons with dementia. However, the research focus has been in long-term care settings with less attention in acute hospitals. We aimed to study the perspectives and experiences of nurses implementing PCC in an acute hospital dementia unit (Care for Acute Mentally Infirm Elders [CAMIE]). Method: This was an exploratory qualitative study involving individual, face-to-face, semi-structured in-depth interviews. A purposive sample of 10 nurses participated in the interview. We employed an inductive thematic analysis approach to analyse the qualitative data. Results: The findings highlighted the positive experiences, for example, meaningful connection with patients and the challenges, for example, managing challenging behaviour in providing PCC. The initial challenges were due to a lack of prior knowledge and experience. Through formal and informal learning, the nurses built confidence and competence, and also provided support to one other. They emphasized the importance of teamwork and camaraderie in the CAMIE team but raised concerns about the negative perceptions of non-CAMIE nurses on the value of their work. Conclusion: Despite the challenges, adequate knowledge and robust organizational level support are the key support for nurses to embrace PCC as their care ethos in the acute care setting.

Purpose This paper challenges the value of consensus within the field of learning disability. In this commentary, the author argues that consensus threatens to silence multiple viewpoints, hides how power operates and stifles creativity. Design/methodology/approach The author focuses on two articles within this special issue to suggest that the consensus celebrated is more about a set of shared values, rather than a set of shared practices. This should make us question the depth of the field’s consensus. Findings The presumption that multiple paradigms can be “unified” actually hides how power operates to resolve disagreements among positive behaviour support, active support and human rights approaches. A similar erasure occurs in the language of “capable environments,” which the author argues obscures the role of individuals, relationships and organizational cultures in impacting quality of life. Research limitations/implications We need to create and build a new interdisciplinary field of challenging behaviour studies that is willing to embrace conflict and disagreement in research, policy and practice. Practical implications The author believes that this approach is more likely to empower people, including people with learning disabilities whose behaviour challenges, family members, and direct support workers because it is more likely to recognize their experiences and expertise. Originality/value A new multidisciplinary field of challenging behaviour studies may encourage more theoretical diversity that makes us challenge the value of consensus and embrace creativity.

Purpose The purpose of this paper is to explore three main areas in relation to the interface between challenging behaviour and offending. Design/methodology/approach The first aim is to explore the labelling of behaviours as challenging or offending behaviour in the light of legal definitions, staff knowledge and beliefs and the mental capacity and mental health acts. The second is to explore challenging behaviour as a risk factor for offending in people with Intellectual Disability (ID).The third aim is to discuss the challenging behaviour as a barrier to discharge from secure services. Findings There is limited research suggesting that challenging behaviour such as physical aggression can lead to longer stay in forensic services, and this warrants further research. Originality/value This paper aims to promote discussion about the interface of offending and challenging behaviour in people with IDs and to promote best practice.

Purpose The purpose of this paper is to consider the needs of children and young people with intellectual disabilities (ID), autism and challenging behaviour including those with mental health difficulties in the light of the article “A reflective evaluation of the Bradford Positive Behaviour Support – In Reach Service”. Design/methodology/approach The author’s reflections on experiences of working with this cohort as a clinician and manager are presented in this paper. Also, this paper presents the following: consideration of recent policy, guidance and literature associated with the provision of support to children and young people with ID or autism at risk of residential placement or hospital admission; reflection on gaps in research and practice in how to best support this group of children, young people and families with complex and diverse needs. Findings The success of the Bradford and other similar services is discussed along with a reflection about the benefits and potential gaps in Positive Behavioural Support services working to meet the needs of this group of children and young people, and their families. Originality/value The importance of areas providing more consistent and high quality multi-agency early preventative support and intensive support for those in crisis is discussed. The need for further research and development of ways of working with this cohort, including harder to reach young people and families, is discussed.

Purpose Without effective support and intervention, young people with learning disabilities and severe challenging behaviour are at risk of placement in out-of-area residential settings or highly specialist child and adolescent mental health service (CAMHS) units. Such placements may be inappropriate and result in significant reductions to the quality of life of young people and their families. This paper aims to evaluate the effectiveness of the Bradford positive behaviour support (PBS) service model in terms of its aims to improve quality of life, develop skills and maintain children living with their families in their own homes. Design/methodology/approach A service evaluation using quantitative and qualitative data from a range of sources to review the effectiveness of the PBS model being applied in Bradford and Calderdale was the methodology used. Findings When consistently implemented, the Bradford positive behaviour support–in reach service may improve quality of life, facilitate skill development in young people and their carers and reduce placements in residential and CAMHS inpatient units. Avoidance of such placements is likely to reduce the overall costs of service commissioning in Bradford. Originality/value This paper evaluates a novel approach being applied by a third sector agency to implement effective PBS with a small group of children, their families and networks. There is scope for this model to be successfully implemented in other areas.

PurposeThe purpose of this paper is to describe the current situation in relation to restrictive interventions, and some actions that could be taken to reduce them. The quality of care provided by inpatient services for people with intellectual disabilities has come under increasing scrutiny in recent years – from Winterbourne View in 2011 to Whorlton Hall in 2019, there has been increasing concern that admission to hospital does not always result in a good outcome for the patients. For some people, it has resulted in further deterioration in their physical and mental health, separation from families and supports and reduced probability of living as part of their community. This is in spite of knowledge and evidence of what good practice looks like.Design/methodology/approachThis paper examines the extent to which inpatient services deliver good practice in treatment and care and, where this is not happening, the extent to which they are subject to effective governance.FindingsPeople admitted to inpatient services can be at risk of poor-quality care and the overuse of restrictive interventions. There is guidance available that addresses what should be in place for them to receive high-quality care and treatment, and this clearly is available to many people. However, others can find themselves placed in increasingly restrictive environments and in circumstances where their human rights are at risk of being breached. There is increasing evidence that these services do not follow good practice guidance in terms of staff skills, development and implementation of effective care plans and governance arrangements that address these issues. Regulators, commissioners and managers could, and should, focus on these issues to ensure that the most vulnerable receive the care and treatment they need while in hospital.Originality/valueService providers are aware of the difficulties in developing alternative community services. This places even more importance on the need to ensure that care and treatment in hospital is of a good standard, and that the use of restrictive interventions is minimised. McGillet al.(this issue) describe the features of a capable environment and it may be that hospitals consider that the requirements are unlikely to be implemented effectively in a ward/unit setting. However, a shift of focus in doing this could result in a reduction in restrictive interventions and a better experience – potentially for both the staff and the patients. And families could have some reassurance that their relative was receiving the best quality care and treatment, and that their human rights were being upheld.

Purpose There is an apparent disconnect between the understanding of best practice and service delivery in the support of people with learning disabilities at risk of behaviours that challenge. We suggest, is a problem of implementation. The purpose of this paper is to explore reasons why this might be the case: a failure to recognise the collective works of successive generations of research and practice; and a failure to address the macro-systems involved and systems changes needed to support implementation. Design/methodology/approach This paper reviews the consensus that exists in respect of best practice. Drawing upon ideas from implementation science the paper highlights the complexities involved in the implementation of all evidence-based practices and uses this as a framework to propose ways in which an infrastructure that facilitates the delivery of services in the learning disabilities field might be built. Findings This paper highlights core recommended practices that have been consistent over time and across sources and identifies the systems involved in the implementation process. This paper demonstrates that many of the necessary building blocks of implementation already exist and suggests areas that are yet to be addressed. Critically, the paper highlights the importance of, and the part that all systems need to play in the process. Originality/value In the absence of any generalised implementation frameworks of evidence-based practice in the learning disabilities field, the paper suggests that the findings may provide the basis for understanding how the gap that exists between best practice and service delivery in the support of people with a learning disability at risk of behaviours that challenge might be closed.

Purpose The purpose of this paper is to provide an individual family-carer perspective on navigating the complex child, adult, education, health and social care systems focussing on what might be needed to get the right support in the right place at the right time for individuals with learning disabilities who display behaviour that challenges. Design/methodology/approach This is a conceptual analysis, drawing on lived experience, policy and practice. Findings Policy and best practice advocate a holistic, person-centred, outcome-focussed approach to supporting individuals with learning disabilities whose behaviour challenges, but the existing complex multiple organisational structures are not conducive to delivering this. Making the system work for people requires focussed leadership across all levels to co-ordinate and align the component parts. It is certainly possible to achieve, but it is currently unclear who will take responsibility for making this happen. Originality/value Families are often the only constant in the lives of people with disabilities. This commentary highlights what is important to and for families when attempts are made to get the right support in the right place at the right time for individuals with learning disabilities who display behaviour that challenges.

Purpose This paper aims to consider the extent to which academic research, as described by the papers in this journal, has helped the large-scale use of positive behaviour support (PBS) with people with learning disabilities whose behaviour may be challenging. Design/methodology/approach The author explores the issue from the perspective of a social care provider seeking to implement PBS successfully across the organisation’s services. Findings The author concludes that research needs to refocus its efforts if it is to make a real contribution and argues that future emphasis should be on implementation. Originality/value This commentary articulates the concerns and experiences of a service provider that has striven to implement effective, evidence-based support, informed by relevant research, for many years. Such a perspective is rarely heard in academic PBS research literature.

Purpose This paper aims to provide a commentary on papers in this special edition concerning the implementation of evidence-based practice from a clinician’s perspective. Design/methodology/approach The commentary makes a number of points drawing on both recent literature and the author’s own experience working as a clinician with children and adults with learning disabilities including those who are autistic whose behaviours can challenge themselves, their parents, carers and support networks. Findings Effective implementation requires clinical expertise to operate within a context of collaboration and partnership working, where co-production with those who have lived experience ensures that what clinicians offer resonates and contributes to improvements in quality of life for all. Originality/value The paper will be of value to clinicians working alongside children and adults with learning disabilities and their families, particularly clinical psychologists and behaviour specialists, and to other stakeholders wanting to enable and facilitate the development of high-quality support.

Purpose This study aims to evaluate the clinical effectiveness of the Mindfulness module of the “I Can Feel Good” programme, an adapted dialectical behaviour therapy (DBT) informed skills programme for a group of intellectually disabled offenders (IDOs). Design/methodology/approach The programme module was delivered to a group of five male IDOs detained under the Mental Health Act 1983 (Revised 2007) at an intellectual disability (ID) rehabilitation hospital based in the UK. The mindfulness module was 12 sessions in length, and it was evaluated using the emotional problems scale (EPS) and the cognitive and affective mindfulness scale-revised (CAMS-R) self-assessment and observational scale. These measures were administered pre- and post-module and used the staff report scales as a primary source of evaluation. Findings Non-parametric testing revealed that there was a reduction in scores post module on the externalising behaviour problem scale of the EPS and increased scores on the CAMS-R observational scale, which would indicate clinical improvement in the IDO’s behavioural presentation, although it was not statistically significant. The internalising behaviour problem scale showed increased signs of anxiety post module, this could be related to increased self-awareness. The CAMS-R self-reported measure indicated reduced mindfulness qualities following the module. Originality/value The results indicate that following the mindfulness module, there was a reduced level of challenging behaviour displayed by the patients with increased signs of emotional regulation. There was also an observed reduction in symptoms of depression and low self-esteem post module.

Background Non‐pharmacological interventions are recommended for the treatment of challenging behaviours in individuals with intellectual disabilities by clinical guidelines. However, evidence for their effectiveness is ambiguous. The aim of the current meta‐analysis is to update the existing evidence, to investigate long‐term outcome, and to examine whether intervention type, delivery mode, and study design were associated with differences in effectiveness. Method An electronic search was conducted using the databases Medline, Eric, PsychINFO and Cinahl. Studies with experimental or quasi‐experimental designs were included. We performed an overall random‐effect meta‐analysis and subgroup analyses. Results We found a significant moderate overall effect of non‐pharmacological interventions on challenging behaviours (d = 0.573, 95% CI [0.352–0.795]), and this effect appears to be longlasting. Interventions combining mindfulness and behavioural techniques showed to be more effective than other interventions. However, this result should be interpreted with care due to possible overestimation of the subgroup analysis. No differences in effectiveness were found across assessment times, delivery modes or study designs. Conclusions Non‐pharmacological interventions appear to be moderately effective on the short and long term in reducing challenging behaviours in adults with intellectual disabilities.

Purpose The purpose of this paper is to provide a commentary on Chan and Baker’s article on the social validity of the Aberrant Behavior Checklist (ABC) by exploring some of the advantages and limitations of this and similar tools designed to classify challenging behaviour. Design/methodology/approach The clinical use of the ABC and similar measures is discussed and contrasted with function-based approaches to assessment. Findings While classification tools such as the ABC have played an important role in developing the understanding of challenging behaviour, they focus exclusively on the individual exhibiting the behaviour and fail to take into consideration the context in which the behaviour occurs. Originality/value Considering behaviour in its social and environmental context can reduce the blame and stigma associated with challenging behaviour.

Purpose “Case-complexity” is a widely used but under-explored concept across health and social care. A region’s Intensive Support Teams (ISTs) had been reporting an increase in “case-complexity”, but had not tested this hypothesis against data. This study aims to investigate this question through a pragmatic mixed-methods approach as part of a wider service evaluation. Design/methodology/approach Health of the Nation Outcome Scales for People with Learning Disabilities (HoNOS-LD) scores were used (n = 1,766) to estimate average “case-complexity” of referrals over an eight-year sample period. Two focus groups for IST staff (n = 18) explored why “case-complexity” appears to be increasing. Participant perspectives were subjected to thematic analysis. Findings Average HoNOS-LD scores have steadily increased over the sample period, suggestive of increasing “case-complexity”. Focus groups identified three broad themes to potentially explain the increased complexity: effects of Transforming Care; people’s changing and unchanging support systems; and issues related to mild and borderline intellectual disability. Many perspectives are grounded in or supported by evidence. Research limitations/implications Implications and limitations of findings are discussed, including areas for further consideration and research. The well-designed “short-cut” is promoted as a strategy for busy professionals in need of practice-based evidence but with limited research time and resources. Originality/value The findings and discussion will be of value to anyone involved in the design, commissioning and delivery of mental health and challenging behaviour services to people with intellectual and developmental disabilities (IDD) under Transforming Care. Study methodology is easily replicable to build broader picture about “case-complexity” among UK’s IDD population.

Background A preponderance of behavioural symptoms is assumed to be the main difference in the manifestation of symptoms of post‐traumatic stress disorder (PTSD) in people with intellectual disability (ID). However, no study so far has assessed the relationship between challenging behaviour (CB) and PTSD. The present study aims to explore this relationship by exploring whether CB is directly related to trauma exposure or whether this relationship is mediated through core symptoms of PTSD. Methods Trauma exposure and current symptoms of PTSD were assessed in 43 adults with mild to moderate ID. Parallel versions were administered to 43 caregivers, including the Aberrant Behaviour Checklist to measure CB. Bayesian mediation analyses were conducted using self‐rated and informant‐rated data. Results The self‐report data showed no associations of CB with trauma exposure or PTSD symptoms. The association between informant‐rated trauma exposure and irritability was mediated by severity and frequency of PTSD symptoms. The associations between informant‐reported trauma exposure and the Aberrant Behaviour Checklist subscales hyperactivity and inappropriate speech were mediated by PTSD symptom severity. Conclusions The relationship between trauma exposure and CB was mediated by PTSD symptoms. PTSD core symptoms should be considered as underlying causes of CB, highlighting the necessity to explore trauma biography and symptoms of PTSD. The improvement of self‐report assessment in people with ID is an important task for future studies.

Purpose This paper aims to evaluate the social validity of the Aberrant Behavior Checklist - Communit y (ABC-C). Design/methodology/approach Thirty-six participants completed a questionnaire in which they identified and commented on items of the ABC-C they saw as problematic. Thematic analysis was conducted on the comments made. Findings All participants identified at least one item of the ABC-C as problematic with six items being so identified by over half the participants. A number of themes were identified in participant comments including ambiguity, judgemental language, child-focussed language, lack of attention to behavioural function and repetition. Research limitations/implications More research is required using empirically based methodologies on measures used to assess people with learning disabilities. This should involve ascertaining the social validity of such measures by soliciting the views of both those being assessed and those assessing. Originality/value This study is the first of its kind to evaluate the social validity of one of the most widely used measures of challenging behaviour for people with learning disabilities.

Purpose of review Challenging behaviour shown by individuals with neurodevelopmental disorders (NDDs) has a major negative impact. There is robust evidence for the efficacy of treatments based on applied behaviour analysis. However, such approaches are limited in important ways - providing only part of the whole solution. We reviewed the literature to provide an overview of recent progress in psychological treatments for challenging behaviour and how these advance the field beyond a purely behavioural approach. Recent finding We identified 1029 articles via a systematic search and screened for those implementing a psychological intervention with individuals with NDD (or caregivers) and measuring the potential impact on challenging behaviour. Of the 69 included studies published since 2018, more than 50% implemented a purely behavioural intervention. Other studies could generally be categorized as implementing parent training, meditation, skill training or technology-assisted interventions. Summary Greater consideration of the interplay between behavioural and nonbehavioural intervention components; systematic approaches to personalization when going beyond the behavioural model; mental health and broad social communication needs; and models that include cognitive and emotional pathways to challenging behaviour; is needed to advance the field. Furthermore, technology should not be overlooked as an important potential facilitator of intervention efforts.

ObjectiveTo evaluate stress and quality of life in parents of children with an intellectual disability (moderate–severe–profound), who attend a Child and Adolescent Mental Health Intellectual Disability Service (CAMHS ID), and to estimate the perceived levels of challenging behaviour and satisfaction with supports.MethodsData from children attending the service from 2014 to 2017, along with clinician and parent rating scales were collected.ResultsMost children had medical comorbidities, autism spectrum disorder (ASD), and challenging behaviours. Half had a diagnosis of a mental health disorder. Less than half received respite care. Challenging behaviours and ASD were found to be correlated with increased parental stress while perception of support was inversely correlated with stress. Intellectual disability, ASD, and parental stress were correlated with a decrease in perceived family quality of life.ConclusionsThis study concurs with previous studies, outlining that parents of children with intellectual disability, in particular, where there is a diagnosis of comorbid ASD and challenging behaviour, experience increased psychological distress and lower quality of life.

Purpose Neuropsychologically informed rehabilitation (NIR) is one approach to supporting people with intellectual disabilities, cognitive impairment and challenging behaviour. This study aims to evaluate a five-day training course in NIR for staff working with adult male offenders with intellectual disabilities in a high secure hospital. The impacts on both the staff who undertook the training and the patients with challenging behaviour were explored. Design/methodology/approach Participants were psychology, nursing and day services staff and male patients. The staff completed a post-training questionnaire and three measures at pre-NIR training, post-NIR training and one-year follow-up. Patients completed four questionnaire measures within the same periods. Findings NIR training was positively evaluated by staff. Staff members’ perceived efficacy in working with challenging behaviour significantly increased post-training which was maintained at follow-up. Thematic analysis showed that the training staff members built their confidence, knowledge and skills. Because of these being high to start with, the study could not evidence statistically significant changes in these. Thematic analysis yielded two main themes, namely, benefits and quality of training, each with their own subthemes. The impacts of the training on patients were difficult to assess related to various factors. Research limitations/implications The knowledge and confidence measures used were limited in scope with an experienced staff group and required development. Practical implications NIR training could assist staff in other secure and community settings in working with people with intellectual disabilities and challenging behaviours. Originality/value This study positively contributes to an area that requires more research.

Background In England, forensic psychiatric hospital services are provided at three security levels: high, medium and low. All are publicly funded and similarly regulated, but medium and low secure services are provided in the private and charitable (PCS) sector as well as the National Health Service (NHS). Originally, medium secure hospital services were conceived as for up to 2 years' inpatient stay, but numbers of longer stay patients have been rising. Little is known about their characteristics or whether they differ between NHS and PCS settings. Aims To describe and compare characteristics of long-stay patients in NHS and in PCS medium security hospital units. Methods Data were extracted from clinical records in 14 NHS and 9 PCS hospital units for all patients fulfilling criteria for long stay: having been in high security for more than 10 years or medium security for more than 5 years or in a mix of both for more than 15 years in total. Results 178 NHS and 107 PCS patients were eligible for inclusion, respectively, 16 and 22% of the total patient populations in these settings. The mean length of stay in a medium or high secure setting was similar: 163 and 164 months. Characteristics of the patients, however, differed between unit type. NHS services admitted more patients from prison and PCS services more from other hospitals. NHS services included a lower proportion of patients with personality disorder or intellectual disability. 'Challenging behaviour' was more prevalent in PCS; a history of absconding was found more often among NHS patients. Conclusions The two systems of service appear to be used differently. More research is needed to explain why patients apparently without behavioural disturbances remain in specialist secure facilities for such a long time and whether their needs are truly being met in the least restrictive environment possible.

Background People with autism spectrum disorder (ASD) can experience affective problems, gastrointestinal (GI) symptoms, sleep problems, and challenging behaviour. This study identified the frequency of affective problems and explored how they related to co-occurring conditions in children and adolescents with ASD. Method Participants were children and adolescents diagnosed with ASD using DSM-IV-TR criteria (n = 95), 40 % (n = 38) of whom also had a diagnosis of intellectual disability (ID). The following scales were completed by the participants’ parents or guardians: Child Behaviour Checklist (CBCL), Gastrointestinal Symptoms Inventory, Children’s Sleep Habits Questionnaire (CSHQ), and the Behaviour Problems Inventory-Short Form (BPI-S). Pearson’s correlations and independent sample t-tests were used to examine the relationships between variables. Two hierarchal multiple regressions examined predictors for affective problems in preschool and school-aged children with ASD. Results Participants scored in the clinical range (69.5 %) and borderline range (10.5 %) for affective problems. Significant positive relationships were found between affective problems and sleep problems, GI symptoms, and challenging behaviour. ID and gender predicted affective problems in preschool aged children. In school-aged children, affective problems were predicted by ID, sleep problems, and aggressive/destructive behaviour severity. However, only 25 % of the variance in affective problems was accounted for. Conclusions Future research is needed to understand how affective problems are impacted by co-occurring conditions in children and adolescents with ASD. Affective problems are prevalent in this population and the quality of life for individuals may be improved if practitioners consider co-occurring conditions during clinical practice. peer-reviewed

People with intellectual and developmental disabilities sometimes engage in challenging behaviours. When behaviours escalate to the point where they pose imminent risk to the safety of people and environments, a crisis occurs that jeopardises community living and participation. In these situations, timely access to crisis stabilisation services is required. We conducted a systematic review of the literature to synthesise evidence on effective crisis stabilisation service models for challenging behaviours. A total of 46 publications met the inclusion criteria. The literature describes a spectrum of crisis stabilisation services of varying intensities including: outreach, outpatient, inpatient, respite, and capacity building through education and training. However, there is limited guidance on how to best structure service models. This review highlights the need for comprehensive and person-centred programme evaluations.

Some people with intellectual disability who have sexually offended require long-term support with risk management. This paper demonstrates how least restrictive practices within a Swiss social care setting are utilised to support a young man with intellectual disability, mental health difficulties and persistent high risks. It is underpinned by the social model of disability, which directs attention away from individual pathology onto environmental support structures. Data was generated through qualitative interviews with the patient, forensic psychologist and social care provider and an in-depth analysis of the patient file. Current approaches to community support are synthesised and applied to this exemplary case. Hence, the analysis compares empirically based patterns from the case with the aims of risk management, person-centred planning and sexual offending treatment, highlighting the mechanisms that enable this support package to work. This results in a novel conceptualisation of sexual offending treatment success that encompasses environmental support structures.

Background In people with intellectual disability (ID) and challenging behaviour, antipsychotics (AP) are often used off-label and for a long period. Despite a lack of evidence for efficacy for challenging behaviour and concerns about common and clinically relevant side effects, complete withdrawal often fails. We postulate three possible hypotheses for withdrawal failure: 1. Influence of subjective interpretation of behavioural symptoms by caregivers and family; 2. Beneficial effects from AP treatment on undiagnosed psychiatric illness, through improvement in sleep or a direct effect on behaviour; and 3. Misinterpretation of withdrawal symptoms as a recurrence of challenging behaviour. Methods To investigate our hypotheses, we have designed a multicentre double-blind, placebo-controlled randomised trial in which AP (pipamperone or risperidone) are withdrawn. In the withdrawal group, the AP dose is reduced by 25% every 4 weeks and in the control group the dose remains unaltered. Behaviour, sleep, psychiatric disorders, withdrawal symptoms and side effects will be measured and compared between the two groups. If drop-out from the protocol is similar in both groups (non-inferiority), the first hypothesis will be supported. If drop-out is higher in the withdrawal group and an increase is seen in psychiatric disorders, sleep problems and/or behavioural problems compared to the control group, this suggests effectiveness of AP, and indications for AP use should be reconsidered. If drop-out is higher in the withdrawal group and withdrawal symptoms and side effects are more common in the withdrawal group compared to the control group, this supports the hypothesis that withdrawal symptoms contribute to withdrawal failure. Discussion In order to develop AP withdrawal guidelines for people with ID, we need to understand why withdrawal of AP is not successful in the majority of people with ID and challenging behaviour. With this study, we will bridge the gap between the lack of available evidence on AP use and withdrawal on the one hand and the international policy drive to reduce prescription of AP in people with ID and challenging behaviour on the other hand. Trial registration This trial is registered in the Netherlands Trial Register (NTR 7232) on October 6, 2018 (www.trialregister.nl).

Purpose Examining the education and training needs of forensic nurses is paramount as services move from the older institutions to new care settings. The purpose of this study was to identify Irish Forensic nurses perceived deficits in their knowledge and skills to assist them to provide effective seamless care for individuals with an intellectual disability within their forensic mental health service, so that appropriate training could be provided. Design/methodology/approach Training needs analysis (TNA) procedures are used as a way of establishing the continuing processional development of staff, as they seek to identify the gaps between the knowledge and skills of an individual and the need for further training. A training needs tool developed by Hicks and Hennessy (2011) was used and completed by nurses working in an Irish forensic mental health service. A total of 140 surveys were circulated and 74 were completed (51 per cent response). Findings The top priority training needs identified were for additional training in research and audit and in the use of technology. Other self-identified training needs included additional training in behavioural management for challenging behaviour, understanding mental health and intellectual disability and dual diagnosis, training in enhancing communication skills and how to work with patients who have an intellectual disability patients specific training on autistic spectrum disorders and a guide and template for advance individual care planning and for caring for the physical health needs and promoting the physical health needs of these patients. Originality/value Despite there being a vast range of training issues identified, the majority of nurses appear to have a clear idea of their training needs to ensure the provision of seamless care for individuals with an intellectual disability within a forensic mental health setting. This TNA has identified the specific needs of nursing staff working at different positions across the interface of intellectual disability and forensic mental health care.

Purpose Concerns about the overuse, misuse and potential abuse of restrictive interventions used to manage people who may exhibit behaviour described as challenging led to revised guidance in England. The purpose of this paper is to examine the implementation of this guidance in organisations providing services for people with learning disabilities. Design/methodology/approach A survey collected data from professionals, on leadership, data use, staff issues and post-incident review. Findings Most senior leaders were seen as acting on the guidance. Data collected were regarded as generally accurate, but less than half of the managers were seen as likely to respond to consistently high or increasing use of restrictive practices. Frontline staff and managers were seen as very significant for reducing restrictive practices. Uncertainty was shown regarding the goals and activities needed to provide post-incident review. Research limitations/implications This exploratory survey may be useful for organisations wanting to audit their implementation of government policy and/or for research on a wider scale to indicate how well societies are implementing policy to reduce restrictive practices. Further research on the survey’s validity and reliability is required. Practical implications Further action is needed to encourage all organisations to implement best practice and government policy. This survey showed that some organisations appear to be committed to and potentially achieving reductions in restrictive practices. Originality/value This paper describes the first survey designed to evaluate organisational efforts to implement an important policy initiative.

Purpose In the Netherlands, as in England, concerns exist about the extent of and frequency with which freedom-restricting measures are applied. The view is that use of these measures needs to decrease. The purpose of this paper is to outline new legislation that is expected to come into force in the Netherlands in 2020. Design/methodology/approach This paper provides a description of legislation entering into force on 1 January 2020. Findings Many of the new legislation’s practical implications remain unclear, including the definition of involuntary care. Research limitations/implications The new legislation will start being monitored directly after coming into force, and only then the authors will make out what works well and what does not. Practical implications Introducing new legislation on coercion is not sufficient. Careful implementation of the legislation is important, including the way it defines involuntary care. Originality/value In 2020, the Netherlands is introducing new legislation on involuntary care for people with an intellectual disability. This includes a definition of involuntary care.

Background Children with intellectual disabilities are likely to present with challenging behaviour. Parent mediated interventions have shown utility in influencing child behaviour, although there is a paucity of UK research into challenging behaviour interventions in this population. NICE guidelines favour Stepping Stones Triple P (SSTP) as a challenging behaviour intervention and this trial aims to evaluate its clinical and cost effectiveness in preschool children with moderate to severe intellectual disabilities. Methods This trial launched in 2017 at four sites across England, with the aim of recruiting 258 participants (aged 30–59 months). The Intervention Group receive nine weeks of SSTP parenting therapy (six group sessions and three individualised face to face or telephone sessions) in addition to Treatment as Usual, whilst the Treatment as Usual only group receive other available services in each location. Both study groups undergo the study measurements at baseline and at four and twelve months. Outcome measures include parent reports and structured observations of behaviour. Service use and health related quality of life data will also be collected to carry out a cost effectiveness and utility evaluation. Discussion Findings from this study will inform policy regarding interventions for challenging behaviour in young children with moderate to severe intellectual disabilities. Trial registration number Clinicaltrials.gov, NCT03086876. Registered 22nd March 2017, https://clinicaltrials.gov/ct2/show/NCT03086876.

Purpose of Review To summarise findings about the prevalence and correlates of challenging behaviour in adults with intellectual disabilities from robust research. We also describe findings on the interplay between challenging behaviour and mental health. Recent Findings Recent studies that have utilised psychometrically evaluated tools, with clear operational definitions, show similar findings on the prevalence of challenging behaviour of about 1 in every 5–6 adults known to services. We describe common correlates identified such as communication impairments, severity of intellectual disability, and living in institutional settings or congregate care. We also describe the complex and multifaceted relationship between challenging behaviour and mental health. Summary Based on recent studies, we propose a revised framework model to help understand challenging behaviour. We propose a number of areas where more research is required, particularly the development of risk tools clinicians can utilise in practice.

Purpose The purpose of this paper is to review a case of a man with intellectual disability, autism and challenging behaviour who presented with vomiting, regurgitations and significant weight loss. Design/methodology/approach The paper examines the case history and identifies challenges contributing to symptom classification and management of a patient with intractable vomiting, regurgitations and significant weight loss. Findings This case illustrates the importance of the multidisciplinary team working required to reduce morbidity and risk of mortality, as well as highlighting some of the challenges associated with coordinating different approaches from different agencies. Pharmacological management did not result in lasting symptom resolution in this case. Difficulties in establishing diagnostic certainty and consideration of whether symptoms could be consistent with rumination syndrome are also discussed. The value of consistent implementation of positive behavioural support is also demonstrated. Originality/value The rapid and dangerous weight loss described in this case is associated with adverse physical health outcomes and has generated significant anxiety resulting in extensive liaison between primary and secondary mental and physical health services. Additionally, it considers whether the symptoms could be attributed to the relatively rare diagnosis of rumination syndrome which is historically underdiagnosed.

BACKGROUND: Longitudinal data on medication use in adults with intellectual disability (ID) are scarce. We describe the longitudinal use of and factors associated with psychotropic medication prescribing in adults with ID living in the Australian community. METHODS: Longitudinal data were obtained from adults with ID in the community in Queensland, Australia, between 1999 and 2015. Participant characteristics and medication use information were extracted from baseline questionnaires and health check booklets. Logistic regression was used to investigate the associations between participant characteristics and psychotropic medication use, commencement or cessation. RESULTS: Longitudinal data were available for 138 participants on 697 reviews. The proportion of participants prescribed psychotropic medications increased from 43% to 54% between 1999 and 2015. The rates of commencement and cessation of psychotropic medications between consecutive time periods ranged from 9% to 18% and 7% to 15%, respectively. Challenging behaviour was associated with psychotropic medication use (adjusted odds ratio = 4.1; 95% confidence interval: 2.1-7.9). Presence of challenging behaviour, either consistent or newly identified, was positively associated with ongoing use or commencement of psychotropic medications. CONCLUSIONS: Psychotropic medications are commonly prescribed to adults with ID. Challenging behaviour is positively associated with ongoing use and commencement.

Objectives: Studies of adults with autism spectrum disorder (ASD) have demonstrated poor outcomes related to independence and everyday living skills compared to the general population. In a sample of 74 adults with ASD who require a high level of support we sought to identify correlates of daily functioning.Methods: We administered questionnaires to residential staff and identified participants' independence level in basic and instrumental activities of daily living.Results: There was no association of age with daily functioning. Higher daily functioning was associated with a better general medical health rating. Functional independence was greater in participants with IQ range of 55 to 65 compared to those with IQ below 55. Language difficulties and behavioral disturbances were not significantly correlated with independence in daily living skills. In this sample, individual had held a median of three different types of jobs in supported employment.Conclusion: Daily functioning in adults with autism generally does not decline with age, but because this was cross-sectional data, this requires further confirmation. Community programs designed for adults with ASD who require a high level of support should focus on overall medical health and promotion of daily living skill building.

Purpose The purpose of this paper is to compare experiences of two parents of adolescents with Autism Spectrum Disorder (ASD) differing in gender, including their daily routines at school and at home, challenging behaviour, social support and future plans for their children. Design/methodology/approach The parents of the two adolescents with ASD were interviewed with open-ended questions related to their children as well as their personal experiences, along with getting their individual responses for the established Satisfaction with Life Scale (SWLS). Findings There were similarities and differences in the parents’ experiences with their adolescent children with ASD. Similarities included a limited social support outside their families, hopes for the future of their children, where in they emphasised the need for some “normality” for their child, and a lack of plan in terms of legal guardianship and written wills after their own time. Some of the differences were also noted in the parents’ description of symptoms of their children, with the father of the female adolescent reporting more negative experiences both with his child, as well as with his spouse, a lack of social support and, subsequently, more “dissatisfaction” on the SWLS than the mother of the male adolescent. Research limitations/implications One of the major limitations of this study is the absence of feedback from the other parent besides the one being interviewed, due to which only one parental perspective was provided here. Social implications There are vital social implications of this study. Both parents reported a limited social support due to which they expressed the need for increasing awareness for ASD in the general society. These findings illustrate the need for a focus on designing interventions for improving outcomes for both parent and child in similar situations. Originality/value This study compared the experiences of two parents of adolescents with ASD, differing in gender and symptomology, but similar in other respects, including the family demographic characteristics and cultural context.

Purpose Siblings of individuals with disabilities provide the most long-term care for an individual with disabilities, yet research on their experiences is limited. A majority of previous research focuses on young siblings from a parent’s viewpoint. The purpose of this paper is to investigate the effects of having a sibling with a disability and behaviour described as challenging from adult siblings’ perspectives. Design/methodology/approach Six adult siblings of individuals with intellectual disabilities and behaviour described as challenging were interviewed about their responsibilities pertaining to their sibling, family relationships and the support that had been provided. The study used semi-structured interview methodology based on interview questions from previous research. Findings Siblings described a multifaceted impact on their lives. They attributed aspects of their career choices, personal characteristics and family dynamics to having a sibling with a disability and behaviour that challenges. Siblings stressed the inadequate support that they have received throughout their lives. They are, in a sense, the invisible carers for their sibling but they are perceived by society as just a sibling. Siblings described an optimistic perspective on their lives, even though they expressed the difficulties that they have faced. Research limitations/implications Due to the recruitment process and limited demographic of the participants, the findings may not be generalisable to the general population of siblings of individuals with disabilities. Further research should focus on a broader population. Practical implications This study reinforces the need for more support for siblings of individuals with disabilities in childhood and in adulthood. Originality/value This paper provides perspectives of individuals that have not been fully represented in previous research.

Purpose The purpose of this paper is to provide a commentary on the article by Chase and McGill from the perspective of Sibs, the only UK-wide charity dedicated to supporting siblings of disabled children and adults. Design/methodology/approach This commentary explores the implication of Chase and McGill’s findings for sibling support. Findings The article highlights how siblings need greater support throughout their life and argues that their views must influence the provision and development of that support. Originality/value This viewpoint focuses on the needs of adult siblings, often a forgotten group facing unique challenges and shared experiences.

Women in secure forensic mental health care require therapy and care that is responsive to their specific needs. Despite the policy recognition that women require a distinct service, evidence based...

Purpose The purpose of this paper is to present the service model and evaluation of Southwark Enhanced Intervention Service (EIS). EIS is an intensive community service for adults with intellectual disabilities whose behaviours challenge in the context of the Transforming Care agenda. Design/methodology/approach The service model is described and the following evaluation data over four years are presented: key performance indicators, descriptive data, clinical outcomes, financial outcomes and qualitative feedback on users’ experience. Findings The EIS has demonstrated good outcomes for a small number of adults with complex needs by supporting them at crisis point locally and preventing hospital admission or a move to a restrictive environment out of area. EIS has also supported the successful transition back to area of a small number of adults with complex needs. The evaluation has shown improvements in behaviour, wellbeing and quality of life as well as demonstrating financial savings. Families’ and providers’ qualitative feedback indicates that the service has been highly valued and in particular the access to timely multidisciplinary coordination of input. Originality/value The service was developed around the same time as the start of the Transforming Care agenda. It presents findings of a four-year evaluation at a time when there is limited evaluation of such service models focusing on the Transforming Care aims. The paper presents significant findings in support of guidance and recommendations published more recently as well as reflections on components of effective service delivery.

Purpose The purpose of this paper is to discuss outcomes of a service redesign, involving an Intensive Support Team (IST) for adults with learning disabilities and challenging behaviour, working in conjunction with a Community Learning Disability Service (CLDS). Design/methodology/approach Two IST staff were physically based as “Inreach workers” within a CLDS for six months. Inreach workers provided support with existing resources and consultation for specific clients presenting with challenging behaviour. CLDS staff confidence, understanding and implementation of existing challenging behaviour resources was evaluated before and after service redesign. An online questionnaire was used to gather further data relating to experiences of the Inreach project. Findings CLDS staff confidence, understanding and implementation of existing challenging behaviour resources increased over the six-month inreach period. Questionnaire results indicated CLDS staff found Inreach support to be beneficial, having a perceived positive impact for clients, and providing clarity on the skills and resources provided by the IST. Research limitations/implications The long-term effects of this pilot have yet to be established. Consideration is given to how demand characteristics may have influenced CLDS responses. Practical implications Careful consideration should be given in terms of how ISTs interface with CLDSs. ISTs may consider being based physically within CLDSs, to provide more readily accessible support. Originality/value Providing CLDS staff with more accessible support from ISTs may increase the effective implementation of available resources for adults with learning disabilities and challenging behaviour.