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Purpose: This study aims to investigate the experiences of frontline managers supervising and developing staff to support autistic adults living in two types of residential housing in the community. Design/methodology/approach: A qualitative approach used semi-structured interviews with 14 frontline managers. Audio-taped material was transcribed and analysed using thematic analysis. Findings: Two main themes emerged. Theme 1 "autism in practice" illustrates commonalities observed to affect autistic adults with learning disabilities receiving staff support; whilst one sub-theme illustrated the diversity in how these commonalities may be experienced and expressed, another focused on participants' experiences of staff concerns regarding behaviours described as challenging. Theme two, "what's important in autism-informed support" reflected participants' perceptions of the features of successful person-centred staff support for autistic service users. Research limitations/implications: The "rich" experiences of these managers may not be readily generalised. Practical implications: Features of good staff support for autistic adults who may show behaviours of concern included attending to individuals' specific communication and sensory needs and for predictability within their environments. Developing staff skills and confidence to implement skilled approaches in the context of often high risk behaviour of concern took time and frontline managers "on site" to observe, coach, mentor and demonstrate good practice. More intellectually (verbally) able service-users were perceived as more "difficult" to support. Social implications: Staff supporting autistic adults in ordinary housing need frontline managers to act as practice leaders rather than administrators. Originality/value: This study is the first to report, to the best of the authors' knowledge, on management for staff supporting autistic adults living in community housing. [ABSTRACT FROM AUTHOR]

Background: Stepping Stones Triple P (SSTP) is a complex parent‐mediated intervention aimed to reduce behaviours that challenge in children with moderate to severe intellectual disabilities, aged 30–59 months. Methods: To formulate a comprehensive understanding of SSTP implementation in the UK, we conducted a process evaluation collecting stakeholder views and considering intervention fidelity, dose, reach, delivery adaptations, and acceptability. Results: Fidelity and quality of delivery ratings were high. Parents perceived SSTP as valuable, reporting increased parental confidence and understanding of the child's behaviours. However, only 30% of families received an adequate dose of the intervention. Parents who only received treatment as usual described feeling abandoned by current services. Service managers emphasised the importance of availability of resources and therapist training for successful intervention delivery. Conclusions: SSTP supports effective management of early‐onset behaviours that challenge. Further work is needed to ensure equitable access to the intervention across health and social care services. Trial Registration: NCT03086876 – https://www.clinicaltrials.gov/ct2/show/NCT03086876?term=Hassiotis+Angela&draw=1&rank=1. [ABSTRACT FROM AUTHOR]

Purpose: Evidence of overprescribing of psychotropic medicines to manage challenging behaviour in people with intellectual disabilities has led to national programmes within the UK to promote deprescribing, such as stopping the overprescribing of medication in people (with learning disabilities, autism or both). To successfully implement deprescribing initiatives, we need to understand how to engage stakeholders in the process. Design/methodology/approach: In a published systematic review, we reported evidence about the process of deprescribing psychotropic medicines for people of all ages with intellectual disabilities and challenging behaviour. As a part of the original review, we searched for evidence about stakeholders' experiences of the psychotropic deprescribing process, which was synthesised and reported within the current study. Findings: Six studies were identified. Involving carers and people with intellectual disabilities, providing ongoing support and improving access to non-pharmacological interventions, including positive behaviour support, may contribute to successful outcomes, including reducing or stopping psychotropic medicines and improving quality of life. Implementing psychotropic deprescribing requires a multidisciplinary collaborative care approach and education for stakeholders. Originality/value: There have been no previous reviews of stakeholder experiences of deprescribing psychotropic medications for people with intellectual disabilities and challenging behaviour. The existing literature is scant, and further research is needed. [ABSTRACT FROM AUTHOR]

Team case formulation on acute psychiatric wards aims to support staff to manage significant levels of challenging behaviour. However, there is limited research on staff experience of case formulation in this setting. This study aimed to investigate staff experience of team case formulation sessions on acute psychiatric wards and their impact on staff wellbeing. Eighteen multidisciplinary staff (nurses, doctors, occupational therapists, support workers, activities coordinators) from five acute wards at a South London psychiatric hospital completed a semi-structured interview and visual analogue scales on their experience of attending case formulation. Thematic analysis was employed to analyse qualitative data. Participants reported that case formulation supported staff to develop a holistic understanding of service users, provided a safe space for staff to discuss the impact of challenging behaviour and improved teamwork and communication. Participants reported that these benefits increased their ability to identify and support the needs of service users and improved therapeutic relationships. Challenges with establishing continuity of care were highlighted. Team case formulation is an important intervention to support ward staff and has significant benefits to staff wellbeing and quality of care. Greater integration with existing ward practices may benefit both staff and service users. [ABSTRACT FROM AUTHOR]

Introduction: The United Kingdom's Department for Education's advice on behaviour focuses on the power of staff and the strength of the policy in challenging behaviour, via rules, sanctions and rewards. We designed a video‐feedback intervention for staff teams in a special educational setting who were working with children with intellectual disability and challenging behaviour. The intervention aimed to raise reflective capacity on relational mechanisms that offer new response possibilities in everyday practices within trans‐disciplinary teams. Method: We conducted research with three teams (between five and seven participants in each). We report findings from two teams who were working with children (aged between 10 and 14) who staff identified as having behaviour that challenged. The intervention consisted of two video‐feedback intervention sessions, using clips of good interactions between themselves and the child and a review. These sessions took place over three or four months. Qualitative analysis was conducted to analyse changes to the language and depictions of the children. Changes to the participants' goals during the intervention were also analysed. Results: The staff's focus on the child's challenging behaviour reduced. Children who were originally depicted as isolated became depicted in relationship with peers and staff. Participants became more curious about the child and his interactions in the school and home environment. The participant's personal goals emerged through their understandings of what it meant to be good. Conclusions: Working with staff teams using video feedback can change the interactions around the child and the relational conceptualisation of the child and family. Further adaptations to the intervention are needed to raise critical reflection on the concepts that circulate around 'behaviour' that structure policy and shape everyday practices. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Positive behavioural support (PBS) is a non-aversive, preventive approach to behavioural management. The use of proactive approaches such as PBS has been suggested for multiple contexts and client groups as part of the restraint-reduction, 'positive-and-safe' agenda in the UK. PBS was introduced into a psychiatric intensive care unit (PICU) in a south Wales forensic service. However, the approach employed needed to be adapted to improve 'goodness of fit' for the PICU setting. This article describes the actions taken in the service to improve the fit of PBS in the PICU. The aims of this paper are to outline some of the barriers to effective implementation of PBS experienced in the PICU and describe what was done to improve implementation and fidelity to the model in this setting. The goodness of fit of PBS in PICU can be improved with some simple adaptations. The value of the PBS model is its flexibility but further evaluation of PBS approaches in PICUs are needed. [ABSTRACT FROM AUTHOR]

Accessible summary: Family members often support people with intellectual disabilities who display challenging behaviour. Family carers should be listened to and included in important decisions. We asked family carers how professional services had helped their relative with challenging behaviour. Family carers said that the care of people with intellectual disabilities who display challenging behaviour can be improved. Family carers sometimes felt left out of decisions and said that they needed more information. Listening to parent carers' experiences can help to improve the services that are provided to people with intellectual disabilities and their families. Abstract: Background: There is relatively little published data that report the experiences and views of family carers of people with intellectual disabilities who display challenging behaviour who are prescribed psychotropic medication. Materials and methods: An online structured questionnaire was created by the Challenging Behaviour Foundation, a UK charity, and family carers of people with intellectual disability. Questions concerned the management of challenging behaviour and asked family carers about their experiences and views on the use of psychotropic medication. Responses were gathered between August and October 2016. Results are summarised using descriptive and inferential statistics and descriptive analysis of free‐text comments. Findings: Ninety‐nine family carers completed the survey. Family carers reported gaps in the holistic and proactive management of challenging behaviour. Whilst some felt involved in decisions around psychotropic medication prescribing, others described feeling marginalised and lacking information and influence. The decision to prescribe psychotropic medication evoked complex emotions in family carers and medication use was associated with mixed outcomes in those prescribed. Family carers identified areas of good practice and those areas where they believe improvements are needed. Conclusions: Psychotropic medication should be only one option in a multimodal approach to challenging behaviour, but this may not always be reflected in current practice. Greater effort needs to be made to ensure that services are equipped to provide optimum care and to embed shared decision‐making into routine practice. [ABSTRACT FROM AUTHOR]

Reducing ‘restrictive practices’ is an issue of national importance, pertinent to all NHS sectors, yet there is poor awareness of the issue in mainstream adult services. Such practices potentially restrict a person's rights to choice, self-determination, privacy and freedom. Challenging behaviour is often the result of unmet needs, communication difficulties or diagnostic overshadowing, but there is a common misconception that patients exhibit such behaviours because of their impaired intellectual abilities or mental health problems. This article seeks to raise awareness of restrictive practices and suggest the way forward. It highlights the importance of good de-escalation skills, which, if adopted early in therapeutic relationships, may help reduce the occurrence of challenging behaviours and situations. Behavioural support plans that adopt a biopsychopharmacosocial approach (BPPS) detail a range of interventions for managing challenging behaviours. Tailored support that follows a BPPS approach could reduce incidents of challenging behaviour, reduce costly observation, improve the patient experience and protect the patient's liberty. [ABSTRACT FROM AUTHOR]

Accessible Summary People with learning disabilities talked about what it was like to move out of hospital. People talked about how important their relationships with other people were. People wanted to feel comfortable with new members of staff so that they felt safe and happy in their new home. People talked about how moving out of hospital changed how they thought about themselves. When they were in hospital, people sometimes thought that they were “bad.” But after they moved, some people started to think that they were a different person. It is important for everyone to think about how they talk to people when they are in hospital, and when they have moved out. People can do really well living in their own home, rather than in hospital. Abstract: Background: People with learning disabilities are moving out of hospitals as part of the Transforming Care programme, although thus far their views on how they have experienced this have not been researched. Materials and Methods: A qualitative design was used to explore how people with learning disabilities experienced moving as part of Transforming Care. Eleven people took part in semi‐structured interviews; they were supported by Key Support People (n = 9) who knew them well. A social constructionist Grounded Theory approach was used in analysis. Results and Discussion: People reported that their relationships with other people, including friends, family and staff, played a significant role in how they experienced the move. Moving was also an opportunity for people to shift their ideas about who they were as a person and opened up a wider array of stories about their identity. Conclusions: A number of recommendations are discussed, relevant for staff working in this field to support positive transitions out of hospital. [ABSTRACT FROM AUTHOR]

Accessible Summary: Lots of people with intellectual disabilities in the UK are given medication to manage their behaviours and the NHS wants this to stop. In Cornwall, we wanted to see how often we give medication to people instead of other health care such as communication or occupational assessments etc. We found that around half the people we work with because of their behaviours get medication to manage their feelings and many do not get other assessments. We want to change this in Cornwall and stop over medicating people by learning from this study. Abstract: Background: The use of psychotropic medication to manage challenging behaviours of people with intellectual disabilities is a contentious issue which NHS England has now focused on. This paper looks to evaluate this within the multidisciplinary context. Method: Records of clients (n = 106) open to a Community Intellectual Disabilities team for care relating to challenging behaviours were examined. Those recommended psychotropic medications in the absence of a mental health diagnosis were scrutinised for supporting MDT assessments. Results: Over half the clients with challenging behaviours were being prescribed psychotropic medications and many of those had very few MDT assessments to inform care. Conclusions: This study demonstrates the extent psychotropics are used in the absence of MDT informed support for people with intellectual disabilities and behaviours that challenge. A vision to simply withdraw such medication might be simplistic. Local MDT plans are in development to systematically reduce reliance on this type of restrictive practice. [ABSTRACT FROM AUTHOR]

Aim: To more fully understand the experiences of seclusion in a learning disability service for women. Background: This paper reports on one of the analytical themes, seclusion, from an ethnographic study exploring the lives of learning disabled women on locked wards. Method: Participant observation was used on three locked wards for women in a learning disability secure (forensic) unit in the United Kingdom. Themes from the analysis of field-notes were used to construct an interview schedule. Sixteen detained women and ten staff participated in interviews. Results: The thematic analysis produced four areas of relevance: the seclusion room environment, reasons for using seclusion, termination of seclusion and alternatives to seclusion. Conclusion: Detained women's descriptions of seclusion portrayed a bewildering, distressing experience which violated their privacy. Alternative practices such as providing a space for anger and resolve, and time for discussion with staff were identified. [ABSTRACT FROM AUTHOR]

Accessible summary We wanted to find out what adults with learning disabilities who receive challenging behaviour services thought about challenging behaviour and the services they receive., We met with people in small groups and talked with them about challenging behaviour., There were barriers to attending the groups like services not having enough staff or transport., People in the groups told us what they thought of words like challenging behaviour, what they understood about challenging behaviour services, and what it was like meeting with them., Abstract Background Following scandals such as Winterbourne view, Department of Health, (A national response to Winterbourne View Hospital, 2012) seeks changes in challenging behaviour services. A key part of this change is ensuring people with learning disabilities who use challenging behaviour services have more personalised support and their voices are heard. Materials and Methods This article describes a study that used focus groups to explore challenging behaviour and challenging behaviour services with people with learning disabilities who used community-based challenging behaviour services. We analysed the focus groups using thematic analysis. Results We found three main themes: Engaging with service terminology: the language of Challenging Behaviour; Locating and Framing behaviour; and Engaging with Professionals. Conclusion People with learning disabilities who receive challenging behaviour services are able to participate in focus groups and tell us about their experiences. Further consideration is required concerning how people with learning disabilities experience their engagement with challenging behaviour services. This study has led to a larger study currently in progress. [ABSTRACT FROM AUTHOR]

The England Department for Education regulations require that all children and youth in care for more than six months must have a ‘permanence plan’. Although, in England, placement in a children's home is generally used as a ‘last resort’ after usually more than one family placement (adoptive or foster) has not worked out, and is usually seen as a short term measure, it is recognised in the guidance that for a small proportion of young people a residential care placement will be the permanence option of choice. After reviewing the relevant literature on the uses of residential care internationally and in the UK, the paper summarises a case study of a small English voluntary sector agency providing longer term care in six small children's home. Summary information is provided on the philosophy and characteristics of the care provided, the over-arching aim of which is to achieve stability and a sense of belonging through the care experience and into adulthood and beyond. Descriptive data are provided on the young adults before and during their stay, and as young adults and outcome data (factual and using ‘sensitive’ outcome measures) are provided on a cohort of the 65 former residents now aged between 18 and 30. [ABSTRACT FROM AUTHOR]

Objectives The use of pharmacological interventions to manage challenging behaviour displayed by adults with intellectual disabilities remains controversial, with current clinical guidelines in the United Kingdom advocating the use of less invasive psychological interventions. This exploratory study aimed to discover what views and beliefs are held by a sample of NHS professionals who provided care and treatment to adults with learning disabilities, about the factors that are influential in the clinical decision-making process, surrounding the prescription of psychotropic medication, to manage challenging behaviour. Methods Q methodology was used to elucidate the factors considered influential in the clinical decision-making process, surrounding the prescription of medication to manage challenging behaviour. 55 participants from a range of services across the north-west of England performed a 104 statement Q-sort task. Results Principle component factor analysis with varimax rotation was performed on the 55 completed Q sorts. This revealed a four factor solution, accounting for 44% of the variance in the data. The factors were interpreted and discussed under the following headings: 'High-quality safe ethical practice', Risk is a rationale for reactive prescribing', 'Pragmatic management' and 'Contextual issues'. Conclusions The study demonstrated that Q methodology is a useful tool for identifying subjective viewpoints held by a range of professionals, with regard to the factors that influence the clinical decision-making process surrounding the prescription of medication. The study suggests that services need to identify the wider contextual factors, which are barriers, to the use of less invasive psychological interventions. [ABSTRACT FROM AUTHOR]

Background: There has been continuing change in the nature of care homes in the UK with 80 % of residents now living with some form of dementia or memory problem. Caring in this environment can be complex, challenging and stressful for staff; this can affect the quality of care provided to residents, lead to staff strain and burnout, and increase sickness, absence and turnover rates. It is therefore important to find interventions to increase the wellbeing of staff that will not only benefit staff themselves but also residents and care providers. Mindfulness training is known to be effective in treating a variety of physical and mental health conditions. Methods and design: The study uses mixed methods centred on a stepped-wedge cluster randomised trial. Thirty care homes in Wales are implementing a brief web-based mindfulness training course, starting in random sequence. Four to ten consenting staff from each facility undertake the course and complete validated questionnaires at baseline and after eight and 20 weeks. We shall also interview a stratified sample of ten trained staff and analyse the transcripts thematically. The primary outcome is stress; secondary outcomes include job satisfaction, attitudes towards residents and sickness absence rates. Discussion: With increasing numbers of people living with dementia in care homes and causing stress in their carers, it is important to evaluate support strategies for staff. Mindfulness-based therapies may be of potential benefit and need detailed examination. [ABSTRACT FROM AUTHOR]

Previous research has suggested that challenging behaviour emitted by persons with intellectual and developmental disabilities negatively impacts upon the levels of stress and burnout of those who support and care for them. In the current study a sample of disability support workers in the UK (N=138) reported their levels of perceived stress, burnout, and commitment to their work. The relationship between the frequency and severity of aggressive/destructive behaviours to which they were exposed, and these three measures were examined. Results showed that participants scored lower on measures of burnout in the current study than has been reported by similar research studies in the UK and North America. The results revealed an association between challenging behaviours experienced and participants' perceived stress and emotional exhaustion. Perceived stress and burnout were also associated with participants' commitment to their work. Finally, a series of regression analyses identified a number of predictors of emotional exhaustion, depersonalization, and personal accomplishment among disability support workers. The results and their implications for the consideration of disability support worker wellbeing and future research in this area are discussed. [ABSTRACT FROM AUTHOR]

Objectives:To estimate incidence, identify consequences and potential risk factors for harm in people with dementia who got lost in one UK policing region. Methods:In a retrospective observational study, data were extracted from missing-person records over a four-year period in one UK policing region (population of 2.1 million). Results:Two hundred and eighty-one incidents of getting lost were identified. Incidence of getting lost was estimated at 0.5% of the regional dementia population. Fifty-nine percent of reports came from domestic settings, 29% from care homes/hospitals, and 12% on excursions from home. Five percent (n= 15) sustained significant harm, including two deaths. Average age was 78 years (SD 8.3). Harm was associated with older age (mean difference 6.16 years, CI 1.86 to 10.46,p= 0.005,t= 2.82), length of time missing (Mdn time 2.48 hours; IQR 0.97 to 9.45,p= 0.02), and season (9% winter, 2% summer,p= 0.006). The length of time missing increased with delays in reporting to police (r= 0.15,p= 0.018), getting lost at night (Mdn time 1.70 hours, IQR 0.52–3.32,p= 0.028), driving themselves (Mdn time 2.45 hours, IQR 0.42–2.00,p= 0.001), and using public transport (Mdn 1.78 hours, IQR 1.07–3.92,p= 0.001). Conclusion:Incidence in this study suggests getting lost is a low-frequency event for people with dementia but for a small minority, the risks are considerable. Exploratory analyses suggest individual and environmental factors increase the risk of harm. Suitable methods need to be developed to replicate these findings in larger prospective samples. A focus on the predictors of harm may aid development of assessment protocols to ensure intervention is proportionate. [ABSTRACT FROM PUBLISHER]

Purpose - A new service was developed to provide transitional care between acute and secure services for people with serious mental illness who are considered "difficult to manage". The purpose of this paper is to evaluate the work of the service by examining referrals made, strategies employed for each referral, and patient outcomes, as well as investigating issues in the service's development and implementation. Design/methodology/approach - A retrospective descriptive study by review of 38 case notes, and qualitative interviews of 47 staff within the service and those referring to the service. Findings - In the first eight months, 38 patients were referred due to violence, aggression and management problems. Most interventions provided by the service involved working with referring staff, rather than direct patient contact. Subsequently, 16 per cent required referral to higher levels of security. Interviews showed the team's aims needed to be more clearly established, but that ward staff found the service to be a useful and productive resource. Research limitations/implications - The study is descriptive and retrospective, but showed that the service provided appropriate interventions for managing patients with serious mental illness and challenging behaviour. Practical implications - A transitional service may have value in keeping patients in the least restrictive setting. Careful planning is needed in designing novel interventions, ensuring clear aims and effective management. Originality/value - The service under study was novel, and may be useful in facilitating successful transfer from, or preventing admission to, secure services. [ABSTRACT FROM AUTHOR]

Purpose - The purpose of this paper is to present preliminary data on a cohort of patients referred to a specialist forensic medium-secure autism spectrum disorder (ASD) service during its first two years of opening and to identify variables associated with admission to the service. Design/methodology/approach - Data on all referrals to the service (n=40) was obtained from clinical files on demographics, offending history, psychiatric history and levels of therapeutic engagement. The sample was divided into two groups: referred and admitted (n=23) and referred and not admitted (n=17). Statistical analysis compared the two groups on all variables. Findings - Totally, 94 per cent of all individuals assessed had a diagnosis of autism, however, structured diagnostic tools for ASD were used in a small minority of cases. About half the sample had a learning disability, almost four-fifths had at least one additional mental disorder and almost three-quarters had a history of prior supervision failure or non-compliance with treatment. The sample had a wide range of previous offences. No significant differences were found between the groups on any of the variables included in the study. Research limitations/implications - The present study presents a starting point to follow up in terms of response to treatment and characteristics associated with treatment outcome. Practical implications - The sample had a wide range of clinical and risk-related needs. Both groups shared many similarities. Originality/value - This highlights the need for comprehensive assessment looking at risk-related needs so that individuals are referred to an optimal treatment pathway. [ABSTRACT FROM AUTHOR]

Purpose - Two censuses, from 2010 and 2013, respectively, shed light on the trend in use of in-patient psychiatric care for people with learning disability or autism following the BBC documentary exposing abuse of patients at Winterbourne View. The purpose of this paper is to consider the implications of the detailed trends for future care for this group. Design/methodology/approach - Published data from a recent (September 2013) census are compared with the re-analysis of a census undertaken by the Care Quality Commission in March 2010. Findings - An overall 35 per cent reduction in numbers of in-patients is made up of larger falls in groups generally easier to discharge (older, female, in general as opposed to secure units). There is also substantial variation around the country. Research limitations/implications - There are some uncertainties about the comparability of the two censuses and the question of how complete enumeration was of people with learning disabilities in general mental illness beds. Originality/vaiue - The paper raise the question of whether the beds that are reducing fastest may be those most likely to be of value to a high quality and sustainable service in the long term. [ABSTRACT FROM AUTHOR]

Background Although staff attitudes towards individuals with intellectual disability (ID) whose behaviour challenges may be an important part of a positive support culture, very little research has focused on the development of training specifically designed to change staff attitudes. Positive contact is hypothesised to be an effective way to change attitudes towards stigmatised groups. Methods We designed and developed a half day training package about the experiences of individuals whose behaviour challenges - Who's Challenging Who ( WCW). The WCW package was delivered according to a manual by a trainer with ID and a professional without disability. Seventy-six staff from a variety of organisations participated in one of 10 WCW training sessions and provided data on their attitudes and empathy towards individuals whose behaviour challenges prior to the WCW training and immediately at the end of training. Staff also completed a post-training evaluation questionnaire. Results A training package was successfully developed collaboratively with individuals whose behaviour challenges, and received very positive evaluations from staff participants. Short-term positive change was shown for empowerment and similarity attitudes, and staff empathy and self-efficacy. These outcomes were associated with small to moderate effect sizes. Conclusions Meaningful short-term positive staff attitude changes were found and the WCW training model was shown to be feasible. More robust research designs are needed for future evaluation. In addition, the function of an attitude change intervention such as WCW within organisations' training strategies requires further development. [ABSTRACT FROM AUTHOR]

Background Temper outbursts are common in Prader- Willi syndrome but rarely described in detail. This study investigated the phenomenology of temper outbursts in terms of antecedents, sequence of behaviours and emotions and intervention strategies used. Method A semi-structured interview about temper outbursts was conducted with the main carers of seven children (9.5 to 16.7 years) and seven adults (24.7 to 47.10 years) with Prader- Willi syndrome (10 male, 4 female). Reliability and validity of the interview results was established. Results Various setting events increased and reduced the likelihood of temper outbursts. The most common antecedent was a change to routine or expectation. There were marked similarities in the sequence of behaviours and emotions during temper outbursts, with anger rising quickly followed by expressions of remorse and distress at the end of an outburst. Discussion The sequence of behaviours and emotions within outbursts was similar to that described in temper tantrums in typical development. Cognitive and emotional processes are likely to be important in the understanding of temper outbursts with implications for early intervention. [ABSTRACT FROM AUTHOR]

Purpose – The purpose of this paper is to report on a personalisation project run by the Challenging Behaviour Foundation (CBF) which aims to share the identified barriers and solutions to personalisation for people with severe learning disabilities and behaviour described as challenging. Design/methodology/approach – A small project team consisting of a project manager, housing specialist and positive behavioural support specialist worked as consultants with selected East Midlands local authority and NHS commissioners and with six families from other areas. Findings – The main barrier to personalisation was the volume of, and priority given to, safeguarding referrals by frontline commissioning social care workers. This reduced capacity for a proactive approach to support planning. Workers who participated in the project appreciated the expertise and support of the project team and the opportunity to reflect on their work. However, a major project limitation was a lack of time for commissioning workers and managers to engage with the project. Practical implications – The project report provided a series of recommendations for action for commissioners of health and social care support and for families. The Winterbourne View scandal broke as the project was established and its findings are helpful to anyone taking forward action plans to improve commissioning practices to avoid the continued commissioning of poor quality care. Originality/value – The project sought direct engagement in planning in "real time" with frontline commissioning staff and the families of people with severe learning disabilities and behaviour described as challenging. It is hoped that the value of the paper will be to influence NHS and LA commissioners to improve their response to people with severe learning disabilities. [ABSTRACT FROM AUTHOR]

Purpose – The purpose of this paper is to identify psychotropic medication being prescribed for people with intellectual disability "as and when required" (PRN); the indications, frequency of use, rate of poly-pharmacy and contribution of PRN medication towards this. The paper also aimed to identify individual and environmental factors associated with PRN medication prescribing. Design/methodology/approach – Data were collected from nursing and medical records for the 119 service users in the acute assessment and treatment unit and NHS residential care settings managed by specialist intellectual disability services covering Leicester, Leicestershire and Rutland over a month period. Data were analysed using descriptive statistics and logistic regression to calculate adjusted odds ratios for predictor variables. Findings – In total, 72 per cent of the service users were prescribed and 25 per cent were administered PRN medication over the study period. The most common indications for PRN prescribing were aggression and agitation. Lorazepam and chlorpromazine were the most frequently prescribed PRN medications. The rate of poly-pharmacy was 41 and 38 per cent of this was attributable to PRN medication. Male gender and history of challenging behaviour were found to be significant factors associated with PRN medication prescribing. Originality/value – PRN medications are commonly prescribed in people with intellectual disabilities and contribute to poly-pharmacy. Whilst PRN medication continues to remain an effective therapeutic option in situations where environmental and behavioural approaches are proving insufficient, their use should always be in conjunction with effective review mechanisms. [ABSTRACT FROM AUTHOR]

Background Many people with intellectual disabilities display high levels of anger, and cognitive-behavioural anger management interventions are used routinely. However, for these methods to be used optimally, a better understanding is needed of different forms of anger assessment. The aim of this study was to investigate the relationship of a range of measures to self- and carer reports of anger expression, including instruments used to assess mental health and challenging behaviour. Method Adults with intellectual disabilities, who had been identified as having problems with anger control, their key-workers and home carers all rated the service users' trait anger, using parallel versions of the same instrument (the Provocation Inventory). In addition, service users completed a battery of mental health assessments (the Glasgow Depression Scale, Glasgow Anxiety Scale and Rosenberg Self-Esteem Scale), and both groups of carers completed a battery of challenging behaviour measures (the Hyperactivity and Irritability domains of the Aberrant Behavior Checklist and the Modified Overt Anger Scale). Results Participants had high levels of mental health problems (depression: 34%; anxiety: 73%) and severe challenging behaviour (26%). Hierarchical linear regression analysis was used to explore the extent to which anger ratings by the three groups of respondents were predicted by demographic factors, mental health measures and challenging behaviour measures. Older service users rated themselves as less angry and were also rated as less angry by home carers, but not by key-workers. More intellectually able service users were rated as more angry by both sets of carers, but not by the service users themselves. Significantly, mental health status (but not challenging behaviour) predicted service users' self-ratings of anger, whereas challenging behaviour (but not mental health status) predicted carers' ratings of service users' anger. Conclusions Service users and their carers appear to use different information when rating the service users' anger. Service users' self-ratings reflect their internal emotional state and mental health, as reflected by their ratings of anxiety and depression, whereas staff rate service users' anger on the basis of overt behaviours, as measured by challenging behaviour scales. [ABSTRACT FROM AUTHOR]

We evaluated the proportion of individuals with Down syndrome (DS: N = 108) who met criteria for autism spectrum disorder (ASD) on the Social Communication Questionnaire and the severity of ASD-related symptomatology in this group. The proportions of individuals with DS meeting the cut-off for ASD and autism in this sample were 19% and 8%, respectively. We then evaluated the behavioural profile of individuals with DS who scored above cut-off for ASD (DS+ASD; N = 17) compared with those with DS-only (N = 17) and individuals with idiopathic ASD (N = 17), matched for adaptive behaviour skills and ASD symptom severity (ASD group only). Individuals in the DS+ASD and ASD-only groups showed more stereotyped behaviour, repetitive language, overactivity and self-injury than the DS-only group (p < .001). Individuals in the DS+ASD and DS-only groups appeared less withdrawn from their surroundings than those with ASD (p < .004). These findings indicate differences in the behavioural and cognitive profile of individuals with DS+ASD compared with those with DS-only, when controlling for adaptive behaviour skills. Individuals with DS+ASD show broad similarities with individuals with idiopathic ASD with regard to ASD and behavioural characteristics but may also show some areas of subtle difference from this group. [ABSTRACT FROM PUBLISHER]

Background Specialist short break services aim to provide enhanced support to family carers as a means of preventing children whose behaviours severely challenge from being placed in full-time residential care. To date, there is limited evidence as to the functioning and effectiveness of such services. Methods In all, 17 children were selected at random from the 123 who were currently receiving services or had done so in the past 2 years from three specialist short break and community support services. For each child, interviews were conducted with a parent, the child's key worker within the service and the professional (mostly social workers) who had referred families to the services. Results Five core themes captured the informants' common experiences: the complexities underlying the provision of services; the negotiations required to implement, maintain and adjust service packages; the relationships forged by the services; and the benefits they brought to children and families plus concerns about the future also featured. Conclusions Specialist short break services can make a vital contribution to retaining children within their families, but under some important conditions which this study has identified: notably, the management of complexity, the formation of trusted relationships and creation of tangible benefits for the family and for the child. [ABSTRACT FROM AUTHOR]

Background The provision of skilled support is dependent on staff knowledge and understanding (Beadle-Brown J., Beecham J., Mansell J., Baumker T., Leigh J., Whelton R. & Richardson L, unpublished data). Influencing staff knowledge and understanding is an important component of interventions. Materials and Methods Fourteen individual semi-structured interviews elicited staff views and experiences of knowledge development. These were analysed using a thematic network analysis (Attride-Stirling 2001, Qualitative Research 1, 385-405). Results Three global themes were identified; skills are developed from experience, service aims influence service delivery and practice is more important than theory. This article focuses on the first of these themes. Relationships between staff and service users played a central role in enabling development of knowledge. Although some skills were seen as transferrable, experience of a particular service user was described as being essential. Conclusions Support staff may not see the relevance of research findings, professional knowledge or training, unless these have involved direct work with the service user in question. [ABSTRACT FROM AUTHOR]

Purpose – Reporting to the police incidents of challenging behaviour displayed by inpatients with autism spectrum disorders (ASD) and learning disability (LD) represents an important but often controversial issue. The purpose of this paper is to contribute to this topic through a brief literature review and the presentation of a clinical case. Design/methodology/approach – Case study and literature review. Findings – The action of reporting to the police can be a useful tool within the therapeutic input provided to patients with ASD and LD who present with challenging behaviour. This can enable staff to feel legally supported, and can promote patients’ learning of social rules, in respect of their rights and duties. The clinical case highlighted that reporting to the police can be effective when it is part of a comprehensive, multi-professional therapeutic process. This should aim at directing patients towards rehabilitation rather than incarceration. This should also entail the identification of clear pathways and ongoing involvement of patients and families. Originality/value – Despite the relevance for clinical practice of the above debate, little has been published on this topic. This paper contributes to this discussion through the presentation of a clinical case and by describing how this issue was addressed within a secure inpatient setting. [ABSTRACT FROM AUTHOR]

Background Children and young people with autism spectrum conditions frequently have adverse experiences in accessing health care. Methods An audit of experiences of families known to our tertiary service and hospital staff was conducted. A checklist asking about particular aspects of behaviour and communication was developed and incorporated into pre-admission planning. Results Awareness of the child/young person's communication needs and behaviours, plus good preplanning by all staff involved and a team member allocated to ensure that the care plan is carried through, has resulted in a vastly improved 'patient experience' from the perspective of family and staff. Conclusion Children and young people with autism spectrum disorder, often with co-existing learning difficulties, vary greatly in their reactions to hospital admission. Preplanning that involves the family with a dedicated informed staff member can dramatically reduce distress and improve the patient and staff experience. [ABSTRACT FROM AUTHOR]

Since 2008, a group of professionals in the UK have collaborated to implement national guidelines on working with people who exhibit challenging behaviours in their region. They have established a formulation planning process for use throughout the region, an audit of clients placed out of area, and a good-practice standards checklist for care managers and social workers to use at annual review. The professionals are also working with commissioners to ensure that the formulation planning process is audited annually, and that the checklist is used at reviews, on entry to new placements and in community teams. [ABSTRACT FROM AUTHOR]

Purpose - This article is the first in a two-part series exploring challenging behaviour, its prevalence, risk factors and causes. The aim of this article is to provide an overview of prevalence studies and explore the various risk factors that have been associated with challenging behaviour. The authors also seek to explore methodological differences across studies that may contribute to the prevalence variations reported in the literature. Design/methodology/approach - The article summarises the findings from frequently cited prevalence studies as well as more recent studies. Findings - The prevalence of challenging behaviour reported in the literature has varied due to methodological differences across studies. Despite this, the best estimate is believed to be from 15 to 17.5 per cent. A range of factors have been associated with challenging behaviour and include gender, age, severity of disability and residential setting. Originality/value - This article appears to represent the most current overview of research in this area. [ABSTRACT FROM AUTHOR]

Background For many adults with an intellectual disability (ID), mealtimes carry significant health risks. While research and allied clinical guidance has focused mainly on dysphagia, adults with a range of physical and behavioural difficulties require mealtime support to ensure safety and adequate nutrition. The extent of need for and nature of such support within the wider ID population has yet to be reported. Methods In this study, we have estimated the prevalence of need for mealtime support among people with ID in the UK, using a population of 2230 adults known to specialist ID services (in Cambridgeshire, UK, total population 586 900). In a sample ( n = 69, aged 19 to 79 years, with mild to profound ID), we characterised the support provided, using a structured proforma to consult support workers and carers providing mealtime support, and health and social care records. Results Mealtime support was found to be required by a significant minority of people with ID for complex and varied reasons. Prevalence of need for such support was estimated at 15% of adults known to specialist ID services or 56 per 100 000 total population. Within a sample, support required was found to vary widely in nature (from texture modification or environmental adaptation to enteral feeding) and in overall level (from minimal to full support, dependent on functional skills). Needs had increased over time in almost half ( n = 34, 49.3%). Reasons for support included difficulties getting food into the body ( n = 56, 82.2%), risky eating and drinking behaviours ( n = 31, 44.9%) and slow eating or food refusal ( n = 30, 43.5%). These proportions translate into crude estimates of the prevalence of these difficulties within the known ID population of 11.9%, 6.6% and 6.4% respectively. Within the sample of those requiring mealtime support, need for support was reported to be contributed to by the presence of additional disability or illness (e.g. visual impairment, poor dentition and dementia; n = 45, 65.2%) and by psychological or behavioural issues (e.g. challenging behaviour, emotional disturbance; n = 36, 52.2%). Conclusions These findings not only highlight the need for a multidisciplinary approach to mealtime interventions (paying particular attention to psychological and environmental as well as physical issues), but also signal the daily difficulties faced by carers and paid support workers providing such support and illustrate their potentially crucial role in managing the serious health risks associated with eating and drinking difficulties in this population. [ABSTRACT FROM AUTHOR]

This article describes a 6-month pilot project in which a community mental health team provided a dementia inreach service into 4 care homes in Birmingham, UK. The project included analysis of the impact of the service at the end of the project as well as a literature review of dementia care in care homes, and especially the issue of antipsychotic medication use and non-pharmacological approaches in managing behavioural and psychological symptoms of dementia (BPSD). The project included training care home staff in the management of BPSD; 2 questionnaires distributed at the beginning of the project found that 65% of care home staff felt a need for education and awareness, practical problem-solving and counselling in managing BPSD. Self-reported knowledge of common mental health problems and dementia increased in care home staff at the end of the project by a margin of 7% and 11% respectively. Reported confidence in managing behavioural problems increased by 9% among care home staff at the end of the project. The project achieved regular monitoring of psychotropic medications, and enabled the discharge of 14 out of 63 existing patients in the selected homes. The project also provided guidance for non-pharmacological techniques for management of BPSD, which included relaxation techniques, distraction techniques, reality orientation, reminiscence work, needs led therapy, music therapy, person-centred approach and behaviour therapy. [ABSTRACT FROM AUTHOR]

Abstract: There is ongoing debate about the best model of service provision for people with an intellectual disability who present severe behavioural challenges. The present paper reviewed research which evaluated a range of UK service provision in terms of impact on challenging behaviour and other quality of life indices. A literature search was carried out for English language papers from 1990 to 2010 using a range of databases. Secondary searches were carried out from references of relevant papers. Very few evaluations were found. The available research indicates that, on the whole, specialist congregate services for individuals with challenging behaviour appear to use more restrictive approaches which have limited effect on reducing challenging behaviour. The evidence for peripatetic teams is somewhat unclear. The two studies reviewed showed positive outcomes, but both had limitations that made it difficult to generalize the results. A similar limitation was found with the sole evaluation of a community based service. It is unlikely that one model of service provision will meet the needs of all individuals, however, more robust evaluations are required of existing service models to allow commissioners, service users, their families and carers to make fully informed choices about effective services for those who challenge. [Copyright &y& Elsevier]

Self-injurious and aggressive behaviours are reported as components of some behavioural phenotypes but there are few studies comparing across syndrome groups. In this study we examined the prevalence of these behaviours and the associated person characteristics in seven genetic syndromes. Questionnaire data on self-injury and aggression, mood, hyperactivity, autism spectrum disorder and repetitive behaviour were collected on Angelman (AS, n = 104), Cornelia de Lange (CdLS, 101), Cri du Chat (CdCS, 58), Fragile X (FXS, 191), Lowe (LS, 56), Prader-Willi (PWS, 189) and Smith-Magenis (SMS, 42) syndromes. A significantly higher prevalence of self-injury was evident in CdCS, CdLS, FXS, PWS, LS and SMS. The prevalence of aggression was significantly heightened in AS and SMS. Self-injury was associated with repetitive and impulsive behaviour in CdLS, FXS, PWS and LS. Impulsivity and overactivity were significantly higher in those showing aggression across all syndrome groups. These data quantify the risk for self-injury and aggression in the syndromes studied with implications for early intervention. The associations between these behaviours and person characteristics both within and between syndromes warrant further research. [ABSTRACT FROM AUTHOR]

People with challenging behaviour are commonly referred to the National Health Service for assistance and support. Good clinical practice would indicate that such interventions should be routinely monitored and evaluated in order to be maximally effective. Challenging behaviour has many impacts and, while monitoring frequency, duration and severity of behaviour is fundamental, equally key is attention to monitoring the impacts on the quality of life of the individual and those with whom they share their environments. Such outcomes are unlikely to be represented by one instrument, and a battery of measures currently holds most promise in relation to representation of what would be considered valid acceptable outcomes. [ABSTRACT FROM AUTHOR]

Background Antipsychotic drugs are used in the routine treatment of adults with intellectual disabilities (ID) and challenging behaviour in the UK despite limited evidence of their effectiveness. There is no evidence on their cost-effectiveness. Methods The relative cost-effectiveness of risperidone, haloperidol and placebo in treating individuals with an ID and challenging behaviour was compared from a societal perspective in a 26-week, double-blind, randomised controlled trial. Outcomes were changes in aggression and quality of life. Costs measured all service impacts and unpaid caregiver inputs. Results After 26 weeks, patients randomised to placebo had lower costs compared with those in the risperidone and haloperidol treatment groups. Aggression was highest for patients treated with risperidone and lowest for patients treated with haloperidol; however, quality of life was lowest for patients treated with haloperidol and highest for patients treated with risperidone. Conclusion The treatment of challenging behaviour in ID with antipsychotic drugs is not a cost-effective option. [ABSTRACT FROM AUTHOR]

Background Perceived problems around the use of physical intervention (PI) to manage challenging behaviour have led to UK initiatives to encourage policy development and accredited training. However, information on PI use and the impact of these initiatives remains limited. Method Adult residential services within an English region were sent a questionnaire regarding PI use, policy, staff training and monitoring/management. Results Physical intervention use was reported by 47% of the services. Of services using PI, 65% reported having a policy governing its use and 79% reported providing staff training. Where restrictive PI was used, comparable figures were 82% for policy and 84% for training. PI use was reported to be monitored in some way by 94% of services. Opinions offered supported the reduction of PI use. Conclusions Physical intervention use is widespread. National guidance on policy and training is widely followed though unimplemented by a minority. The time may be right to more explicitly aim for a reduction in PI use within services. [ABSTRACT FROM AUTHOR]

Management of dementia should focus on the maintenance of function and independence for the person with the disease. Non-pharmacological interventions to manage dementia include reality orientation, aromatherapy and validation therapy. Non-pharmacological ways of managing challenging behaviour are recommended in current guidance. Drug treatments, which may stabilize the symptoms of Alzheimer's disease or slow down further progression for a time, have been available in the United Kingdom since 1997 and may help some people with dementia. There are high levels of stress, distress and psychological illness in family caregivers of individuals with dementia, and practitioners are well placed to signpost carers to appropriate support organizations. [ABSTRACT FROM AUTHOR]

The author discusses the legal, social, and ethical implications of the concept of zero tolerance in caring people with learning disabilities by the Department of Health (DH) in 1999 in Great Britain. According to observations, zero tolerance is perceived as a practitioner's right to safety in the work environment despite an existing disability of the perpetrator. In addition, over-reporting of incidents will increase police involvement which may de-sensitize some individuals.

Background Evaluative studies have shown that special units for people with intellectual disabilities (ID) who have challenging behaviour have advantages and disadvantages. There has been no survey of their number or characteristics for nearly 20 years. Methods A questionnaire was sent to all National Health Service trusts that had ID inpatient beds, and all private or voluntary healthcare establishments providing services for people with mental health problems or ID. This asked for information about the unit, its residents and the views of the unit manager. Results Forty-four agencies confirmed that they provided assessment and treatment units, of which 38 returned questionnaires. These units served 333 people, of whom 75% had mild or moderate ID. A quarter had been there for more than 2 years. Forty per cent of residents had a discharge plan, and 20% had this and the type of placement considered ideal for them in their home area. The main strengths of the units were identified as the knowledge and experience of the staff and having sufficient staff; the main problems as inappropriate admissions, bed-blocking and the relationship with other services; difficulties with recruiting and retaining staff; the location and environment of the unit; and the mix of residents. Conclusions There has been an increasing rate of provision of special units, which now predominantly serve people with moderate or mild ID. This model of service provision is becoming more widespread, but the potential problems identified 20 years ago are still present. Areas are identified for further research. [ABSTRACT FROM AUTHOR]

The author argues that the Millfields Charter's proposal to prohibit the use of prone restraint is based on a misinterpretation of the research evidence and not the solution of the founders of the charter which they believe it to be. He outlined an alternative strategy to enhance service user's safety which is claimed to be effective. He also tackled the risks involved with the procedure and dangers in banning a prone restraint.

The author discusses the initiation of the Millfields Charter which aims to encourage debate about best practice in staff training in physical interventions in October 2005 in Great Britain. He asserted that to assess best practices in staff training, it is needed to look at the political climate in the country concerning the uses and abuses of physical interventions (PI). He examined myths about the impact of staff training in PI on practices including staff training leads to fewer injuries.