Brief report: Aggressive challenging behaviour in adults with intellectual disability following community resettlement

Brief report

Aggressive challenging behaviour in adults withintellectual disability following community resettlement

S. Bhaumik,1,2 J. M. Watson,1 J. Devapriam,1 L. B. Raju,1 N. N. Tin,1 R. Kiani,1 L. Talbott,1

R. Parker,1 L. Moore,1 S. K. Majumdar,1 S. K. Ganghadaran,1 K. Dixon,1 A. Das Gupta,1

M. Barrett1 & F. Tyrer1,2

1 Leicestershire Partnership NHS Trust, Leicester Frith Hospital, Leicester, UK2 Department of Health Sciences, University of Leicester, Leicester, UK

Abstract

Background Aggressive challenging behaviour iscommon in adults with intellectual disability (ID)in long-term care facilities. The government’s com-mitment to the closure of all facilities in Englandhas led to concerns over how to manage this behav-iour in the community. The aim of this study was toassess changes in aggressive challenging behaviourand psychotropic drug use in adults with ID follow-ing resettlement using a person-centred approach.Method The Modified Overt Aggression Scale wasadministered to carers of 49 adults with ID prior todischarge from a long-stay hospital and 6 monthsand 1 year after community resettlement.Results All areas of aggressive challenging behav-iour reduced significantly between baseline and 6

months following resettlement (P < 0.001). Thisreduction remained (but did not decrease further)at 1-year follow-up.Conclusions Further work is needed to evaluate therole of environmental setting on aggressive challeng-ing behaviour in adults with ID.

Keywords intellectual disability, aggression,deinstitutionalisation, hospital, community

Introduction

Aggressive challenging behaviour (verbal aggression,destructiveness, self-injury and physical aggression)is common in adults with intellectual disability (ID)and is a major contributor of the more widelyresearched challenging behaviour (Emerson et al.1994). The government’s commitment to theclosure of all NHS long-term care facilities by theyear 2010 in England (Department of Health 2006)has raised concerns about how to manage thisbehaviour in the wider community, particularlywhere it risks causing harm to others.

A number of reviews have been carried out toassess the effect of moving from institutional tocommunity-based settings (Emerson & Hatton1996; Young et al. 1998; Kim et al. 2001). Generally,improved outcomes following resettlement havebeen observed in terms of increased adaptivebehaviour, greater community participation andincreased contact with friends and family. However,the evidence for a corresponding decrease in chal-lenging behaviour has been inconsistent. One of thedifficulties with studying this area is that the

Correspondence: Sabyasachi Bhaumik, Leicestershire LearningDisability Service, Leicester Frith Hospital, Groby Road, LeicesterLE3 9QF (e-mail: [email protected]).

Journal of Intellectual Disability Research doi: 10.1111/j.1365-2788.2008.01111.x

volume 53 part 3 pp 298–302 march 2009298

© 2008 The Authors. Journal Compilation © 2008 Blackwell Publishing Ltd

mailto:[email protected]

prevalence of challenging behaviour tends to behigher in institutional settings because people whodisplay challenging behaviours are more likely to beadmitted and to remain in these settings (Lakinet al. 1983). However, institutional settings them-selves have also been found to provoke feelings ofanger, helplessness and frustration (Black et al.1997), which are associated with aggressive behav-iour (Tyrer et al. 2006) and one might thereforeexpect to see a reduction in aggressive challengingbehaviour following community resettlement.

Evidence for the effective management of chal-lenging behaviour has also been inconsistent in thispopulation. Antipsychotic drugs are frequently pre-scribed for challenging behaviour in long-term carefacilities (Robertson et al. 2000; McGillivray &McCabe 2005), particularly in people with ID whohave been moved from institutional to community-based placements (Molyneux et al. 1999). However,recent evidence suggests that antipsychotic agentsmay not be as effective as previously thought forchallenging behaviour (Tyrer et al. 2008), which hasled to recommendations for research into alternativestrategies.

The aims of the present study were to assesswhether there was a change in aggressive challeng-ing behaviour in adults with ID following commu-nity resettlement using a person-centred approach.We also aimed to investigate any changes in psycho-tropic drug use over this time period.

Methods

This was a study of the last 51 adult residents toleave a long-stay hospital in Leicestershire and berelocated to a number of community-based place-ments between 2004 and 2006. The hospital waspurpose-built in 1985 to accommodate adults withID who had long-term care needs and included alarge proportion of people with severe challengingbehaviour and profound and multiple disabilities.The study was approved by the institutional reviewboard and was conducted under Good ClinicalPractice guidelines. Two participants were notincluded in the subsequent analysis because theydied prior to their first assessment followingresettlement. Of those remaining, 36 (73%) weremen (mean age 50.8; range 31–73 years) and 13

(27%) were women (mean age 49.3; range 35–96

years). All participants were white and generally fellinto the more severe end of the ID spectrum (asdetermined using the Vineland Scale (Sparrow et al.1984): 34 individuals (69%) had profound ID; 11

(22%) had severe ID; three (6%) had moderate IDand one individual (2%) had mild ID. Many indi-viduals also had co-existing health problems; 36

(73%) were incontinent, two (4%) had a hearingimpairment; 17 (35%) had a visual impairment; 30

(61%) had mobility problems and 32 (65%) suf-fered from epilepsy.

Aggressive challenging behaviour was assessedusing the Modified Overt Aggression Scale(MOAS) (Yudofsky et al. 1986; Kay et al. 1988). TheMOAS was designed to measure four types ofaggression: verbal aggression; destructiveness(aggression towards objects); self-injury (aggressiontowards self) and physical aggression (aggressiontowards others) among people with psychiatric dis-orders. It has been found to have good psychomet-ric properties in terms of test–retest reliability andinter-rater reliability in the general adult population(Sorgi et al. 1991; Kho et al. 1998) and good inter-rater reliability in the adult ID population (Oliveret al. 2007). The scale involves scoring each type ofaggressive challenging behaviour as a score rangingfrom 0 (absence of behaviour) to 4 (severe behav-iour). For this study, we used the MOAS to assessaggressive challenging behaviour at baseline(defined as 6 months prior to discharge from hospi-tal) and at 6 months and 1 year following commu-nity resettlement. Assessments were carried out withthe individual’s formal carer (members of staff inthe hospital or community setting as appropriate)by specialist health professionals. At baseline, 76%(n = 37) of participants had an overall MOAS scoreof 4 or more (median score 16) and thus fulfilledthe criteria for having aggressive challenging behav-iour. More than two-thirds (67%) of participantswere also taking psychotropic drugs for mentalhealth problems or challenging behaviour at base-line (mean number of drugs 1.8), most commonlylow-dose antipsychotic agents [27% (n = 13)typical; 20% (n = 10) atypical and 6% (n = 3) both],which were prescribed to more than half (53%) ofindividuals.

Prior to relocating patients a multi-disciplinarygroup of specialist health and social care profession-

299Journal of Intellectual Disability Research volume 53 part 3 march 2009

S. Bhaumik et al. • Aggression following community resettlement


als met regularly to discuss the intended resettle-ment process. Residents, their family members(where possible), advocates (for residents who wereunable to express their views independently) andformal carers were all involved in the decision-making process. A person-centred approach wasadopted whereby residents were encouraged todiscuss their preferences and needs, so that suitableplacements could be chosen. All adults were relo-cated to supported living accommodation, commu-nity residential homes or nursing homes. Themajority of residents (n = 38; 78%) were moved tosupported living accommodation (individual flatswithin a complex for people with ID developedthrough needs assessment, in collaboration withhousing services, support services and the indi-vidual) with a mean number of residents of 9.7(range 3–16). A further six individuals (12%) wererelocated to group residential homes (mean numberof residents 5.8; range 4–15). The remaining fiveindividuals (10%) were relocated to nursing homes(mean number of residents 14.6; range 5–21).

Statistical analysis

Statistical analyses were adapted to a repeated mea-sures design. Differences between absolute scoreson the MOAS scale at baseline and post-relocationwere compared using the Wilcoxon signed-rankstest. All analyses were carried out in Stata version9.0 (StataCorp 2005).

Results

We observed statistically significant reductions inMOAS scores at 6-month post-resettlement forpeople moving to supported living (n = 38), residen-tial homes (n = 6), nursing homes (n = 5) and thegroup as a whole (Table 1). These reductions wereseen for all four types of aggressive behaviour, inboth men and women and in those aged 50 years orover and under 50 years. Absolute MOAS scores,reduced for 39 individuals, remained the same forfive individuals and increased for four individuals.

Table 1 Aggressive challenging behaviour (median overall MOAS score) and psychotropic drug use among former residents of a long-stayhospital following resettlement in the community

Characteristic Baseline Six months P† One year P‡

Aggressive challenging behaviourMedian overall MOAS score

All participants (n = 49) 16.0 3.0 <0.001 2.0 0.47Men (n = 36) 12.5 1.5 <0.001 1.0 0.86Women (n = 13) 16.0 4.0 0.002 3.0 0.29Age* < 50 (n = 25) 16.0 3.0 <0.001 3.0 0.60Age � 50 (n = 24) 15.0 2.5 <0.001 0.5 0.13Moved to supported living (n = 38) 15.0 3.5 <0.001 1.5 0.04Moved to residential home (n = 6) 16.0 0.0 0.05 1.0 0.09Moved to nursing home (n = 5) 16.0 9.0 0.04 3.0 0.48

Psychotropic drug usePercentage on psychotropic drugs (n) 67% (33) 65% (32) 1.00Percentage on antipsychotic drugs (n) 53% (26) 55% (27) 0.32(Median BNF equivalent dose¶) (24%) (22%) –Percentage on antidepressant drugs (n) 24% (12) 22% (11) 0.32Percentage on hypnotic/anxiolytic drugs 18% (9) 18% (9) 1.00Percentage on mood stabilising drugs 14% (7) 10% (5) 0.16

* Age on 1 March 2004.† Test for a difference between characteristic at baseline and 6 months after resettlement.‡ Test for a difference between characteristics at 6 months and 12 months after resettlement.¶ Percent of British National Formulary (BNF) recommended dose.MOAS, Modified Overt Aggression Scale.




No further change was seen at follow-up. The useof psychotropic medication remained unchangedover the study period.

Discussion

Our findings reveal a strong and fairly consistentreduction in observed aggressive challenging behav-iour in residents of a long-stay hospital 6 monthsand 1 year following community resettlement anddiffer somewhat from previous studies which havegenerally shown little change in challenging behav-iour after deinstitutionalisation (Emerson & Hatton1996; Young et al. 1998; Kim et al. 2001). An overallreduction in aggressive challenging behaviour wasseen in 80% of participants and only four individu-als’ behaviour worsened.

Our study is limited to a small sample size andlack of a control group. We are unable to assesswhether a similar reduction in challenging behav-iour would have been seen had participantsremained in hospital. Residents were aware of theimminent resettlement plans and some becameunsettled prior to relocation, which may haveincreased their reported levels of aggressive chal-lenging behaviour at baseline and thus led to anoverestimation of the reduction in aggressive chal-lenging behaviour we have observed. We are alsounable to control for potential reporting bias asboth carers and professionals were committed tothe new policy.

Nonetheless, it is unlikely that the reduction inverbal aggression, destructiveness, self-injury andphysical aggression we have observed can be totallyexplained by these limitations. It is possible thatfactors found to be associated with relocation, suchas improved quality of life, greater community par-ticipation and increased contact with friends andfamily (Emerson et al. 1994; Dagnan et al. 1998;Young et al. 1998; Kim et al. 2001) played a role inreducing anger and frustration and thus led to adecrease in aggressive challenging behaviour in ourpopulation. The reduction in aggressive challengingbehaviour we have observed may also be due tocareful advanced planning and the person-centredapproach adopted by care home staff, socialworkers and other specialist health professionals. Itis likely that the success of resettlement depends on

appropriate consideration of individual needs. Thereis no ‘one placement fits all’ solution; any two indi-viduals relocated to the same setting are unlikely tohave the same outcome.

Finally, we hope that this study will highlight theimportance of finding appropriate placements forpeople with ID who are relocated in the commu-nity. In a broader context, further work is needed toexamine the role of the environmental setting in theexacerbation or reduction of aggressive challengingbehaviour.

Acknowledgements

We gratefully acknowledge the Leicestershire Part-nership NHS Trust and the Department of HealthPolicy Research Programme who provided fundingfor this study. We would also like to thank allclients, carers and health professionals involved inthe relocation process.

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Accepted 4 July 2008




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Brief report: Aggressive challenging behaviour in adults with intellectual disability following community resettlement