Prevalence of aggressive challenging behaviours in intellectual disability and its relationship to personality status: Jamaican study

Manifestations of personality impairment severity: comorbidity, course/prognosis, psychosocial dysfunction, and 'borderline' personality features

Impairment in personality functioning (briefly, personality impairment) is the core pathology in personality disorder (PD) and an essential indicator of PD-severity. It also is a difficult construct to define and assess. We argue that personality-impairment severity is a latent construct that can be modeled with four indicators: within-PD comorbidity, problematic course/prognosis of both PD and comorbid clinical syndromes, PD-associated psychosocial dysfunction, and features of DSM-5-II borderline PD (BPD). Our literature review documents interrelations among the first three indicators, and studies of PD structure reveal a higher order factor of general PD severity marked most strongly by BPD features. Together, these findings indicate that BPD features may be helpful in the important tasks of defining and assessing personality-impairment severity.

Nidotherapy compared with enhanced care programme approach training for adults with aggressive challenging behaviour and intellectual disability (NIDABID): cluster-randomised controlled trial

BACKGROUND

Aggressive challenging behaviour is very common in care homes for people with intellectual disability, and better psychological treatments are needed. Nidotherapy aims to change the environment of people with mental illness and is an appropriate treatment for this group of disorders.

METHOD

The design was a cluster randomised trial of 20 care homes in which the staff either received training in nidotherapy or the enhanced care programme approach (ECPA), with equivalent duration of treatment in each arm. Cluster randomisation of care homes was carried out at the beginning of the study by an independent statistician. Primary and secondary outcomes were not specified exactly in view of absence of previous study data, but changes over time in scores on two scales, the Modified Overt Aggression Scale and the Problem Behaviour Check List were the main outcome measures. Serious violent incidents were recorded using the Quantification of Violence Scale. All these measures were recorded monthly by research assistants who were carefully kept blind to the allocation of treatment.

RESULTS

A total of 200 residents entered the trial, 115 allocated to the ECPA arm and 85 to the nidotherapy one. Seven residents left the care homes in the course of the study, and six were replaced; these were included 79 in the analysis as the trial was a pragmatic one. There were no material reductions in challenging behaviour in the first 8 months of the trial in either group, but in the last 7 months, those allocated to nidotherapy had a 33% reduction in Modified Overt Aggression Scale (MOAS) scores and a 43% reduction in Problem Behaviour Check List scores compared with 5% and 13%, respectively, for the ECPA group, differences which for the MOAS were close to statistical significance.

DISCUSSION

Nidotherapy shows promise in the management of aggressive challenging behaviour in care homes, but a delay in its benefit might be expected if given to staff only. The treatment is worthy of further evaluation and development.

The Problem Behaviour Checklist: short scale to assess challenging behaviours

BACKGROUND

Challenging behaviour, especially in intellectual disability, covers a wide range that is in need of further evaluation.

AIMS

To develop a short but comprehensive instrument for all aspects of challenging behaviour.

METHOD

In the first part of a two-stage enquiry, a 28-item scale was constructed to examine the components of challenging behaviour. Following a simple factor analysis this was developed further to create a new short scale, the Problem Behaviour Checklist (PBCL). The scale was subsequently used in a randomised controlled trial and tested for interrater reliability. Scores were also compared with a standard scale, the Modified Overt Aggression Scale (MOAS).

RESULTS

Seven identified factors - personal violence, violence against property, self-harm, sexually inappropriate, contrary, demanding and disappearing behaviour - were scored on a 5-point scale. A subsequent factor analysis with the second population showed demanding, violent and contrary behaviour to account for most of the variance. Interrater reliability using weighted kappa showed good agreement (0.91; 95% CI 0.83-0.99). Good agreement was also shown with scores on the MOAS and a score of 1 on the PBCL showed high sensitivity (97%) and specificity (85%) for a threshold MOASscore of 4.

CONCLUSIONS

The PBCL appears to be a suitable and practical scale for assessing all aspects of challenging behaviour.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© 2016 The Royal College of Psychiatrists. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.