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Challenging Behaviour
& Mental Health: Prevention,
Early Intervention & Ongoing Support
Eric EmersonInstitute for Health Research
Lancaster University
The Plan …
• Summarise the evidence– 10 things we know ….
• Implications– Prevention – Early intervention– Ongoing support
Ten Things We Know ….
1. Many people with intellectual disabilities have significant challenging behaviours or diagnosable mental health problems
Prevalence
• Challenging behaviour– 5-15% of service
users– 25-75 people per
100,000– 1,000-3,000 per 4
million
• Mental health– Children
• 40% of children with intellectual disabilities have diagnosable mental health problem
• 10% of all children who have diagnosable mental health problem have intellectual disabilities
– Adults?
Ten Things We Know ….
1. Many people with intellectual disabilities have significant challenging behaviours or diagnosable mental health problems
2. Need is inequitably distributed
The Geography of Need
• Social deprivation is associated with significantly increased risk of– (Less severe) intellectual disability– Challenging behaviour/mental health
• In 1999, 60% of British children with intellectual disabilities and a diagnosable mental health problem were living in poverty
Household Income & Risk of Child Mental Health Problems in Britain
1
2
3
4
5
6
1 2 3 4 5
Equivalised Income Quintile
OR
Conduct DisorderEmotional DisorderID
The Geography of Need
• Social deprivation is associated with significantly increased risk of– (Less severe) intellectual disability– Challenging behaviour/mental health
• In 1999, 60% of British children with intellectual disabilities and a diagnosable mental health problem were living in poverty
The Goals of Health Policy
• Health gain• Health equity
– The highest attainable standard of health should be within reach of all 'without distinction for race, religion, political belief, economic or social condition' (1998 World Health Declaration)
Ten Things We Know ….
1. Many people with intellectual disabilities have significant challenging behaviours or diagnosable mental health problems
2. Need is inequitably distributed3. People do not ‘grow out’ of these
problems
Ten Things We Know ….
1. Many people with intellectual disabilities have significant challenging behaviours or diagnosable mental health problems
2. Need is inequitably distributed3. People do not ‘grow out’ of these
problems4. There are very significant costs
associated with these problems
Ten Things We Know …
5. The factors causing &/or maintaining challenging behaviour/mental health problems are varied and complex
– Biological • Genetics, neurobiological &
medical/psychiatric processes
– Social – Psychological/behavioural processes
• Control & power (communication)
Ten Things We Know …
6. Some approaches to intervention can work– Positive
behavioural approaches
– Some drugs
7. Some do not– Semi-detached
housing therapy– Some drugs
Ten Things We Know …
8. Intervening in adulthood is tough ….
9. … and difficult to sustain10.Most people with significant levels
of need do not get access to evidence-based support
Checklist
• Coverage?• Equitable?• Longer-term
commitment?• Range of
expertise?
• Individualised?• Contextualised?• Evidence-based?• Effectively
monitored & managed?
Main Implication ….
• The importance of adopting a more ‘public health’ perspective
• Invest in prevention and early intervention– The case for prevention and early
intervention– The viability of ‘therapeutic models’
The Case for Prevention & Early Intervention
• Efficiency– Best use of resources
• Evidence– Generic (direct)– Specific (but indirect)
The Viability of the ‘Therapeutic’ Model
• ‘Interventions’, ‘therapies’ and ‘therapists’ are unlikely to solve the problem– Capacity to deliver interventions at an
appropriate scale– Effectiveness of current and future
therapies– Growing need/demand
A Comprehensive Strategy
• Prevention• Early intervention• Ongoing support (technical,
practical & emotional)– For people with intellectual
disabilities – For carers
Social Determinants of Health
Health StatusSEP
Accumulated Risk of Exposure
Across the Lifecourse
Physical Hazards(cold/damp housing,air pollution, toxins, accidents, nutrition
arduous work)
Psychosocial Hazards
(low status & control, uncertainty,‘life events’)
Social Determinants of Health
Health StatusSEP
Accumulated Risk of Exposure
Across the Lifecourse
Physical Hazards(cold/damp housing,air pollution, toxins, accidents, nutrition
arduous work)
Psychosocial Hazards
(low status & control, uncertainty,‘life events’)
Vulnerability &Resilience
Biological(embedded organ
weaknesses, fitness)
Psychosocial (human capital,social affiliations& social capital)
Health Care(including prevention)
Prevention
• Universal and targeted interventions to ….. – Reduce exposure to
potential material & psychosocial hazards
• General risk reduction– Poverty reduction– Reducing risk in
neighbourhoods & communities
• Specific risk reduction– Child protection– Improving parenting
British Medical Association Guidance
• ‘The reforms outlined in the Child Poverty Review must be implemented to end child deprivation and therefore reduce risk factors for mental health problems.’
BMA (June 2006)
Prevention
• Universal and targeted interventions to ….. – Reduce exposure to
potential material & psychosocial hazards
– Reduce vulnerability and promote resilience
• General risk reduction– Poverty reduction– Reducing risk in
neighbourhoods & communities
• Specific risk reduction– Child protection– Improving parenting
Some Aspects of Resilience
• Nurturing, affectionate and secure relationships with one parent
• Supportive relationship with one other adult
• Positive, rewarding school environments• Positive personal achievements • Sense of ‘connectedness’ to the school
and/or local community• Involvement in pro-social peer groups
Early Intervention• Extensive (but indirect) evidence of
efficiency• Effective programmes
– begin early– offer intense support– intervene directly with the child & family– are comprehensive and flexible – need to be long-term – are effectively targeted– take account of family circumstances
Pieces of the Jigsaw
PreventionEarly identification and interventionOngoing support
Development & delivery of interventions Practical & emotional support Effective management
Some Issues ….
• Congregate or non-congregate services?• Role of Assessment & Treatment Units?• Separating out support and intervention
functions• Strengthening & supporting the
commissioning of local options (SCIE)– Workforce planning– Regulation & performance management – Person-centred solutions
Copy of the slides …..
eric.emerson@lancaster.ac.uk
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