Author
DE WINTER C.F.; JANSEN A.A.C.; EVENHUIS H.M.;
Physical conditions and challenging behaviour in people with intellectual disability: a systematic review.
Journal citation/publication details
Journal of Intellectual Disability Research, 55(7), July 2011, pp.675-698.
Summary
Although forty-five studies were included in this systematic review, only eleven were judged as being of reasonable quality. These studies indicate that a number of physical conditions are associated with challenging behaviour in people with intellectual disability. It is suggested that other medical conditions, where pain and discomfort could lead to challenging behaviour, should be further investigated.
Context
The prevalence of challenging behaviour in people with intellectual disability is estimated to be between ten and fifteen percent, the most common forms being aggression, destructive behaviour and self injury. It has been suggested that physical factors, such as pain and discomfort from undiagnosed medical conditions, could play an important role in some types of challenging behaviour. The aim of this systematic review was to investigate which physical conditions are associated with challenging behaviour in this population.
Methods
What sources were searched?
Medline/PubMed and the Cochrane Database of Systematic Reviews were searched for articles published between January 1990 and July 2008, and the reference lists of potentially relevant papers were screened.
What search terms/strategies were used?
Searches were carried out using a combination of MeSH terms and free text searching. Search terms for intellectual disability, problem behaviour, and a range of physical conditions, were combined. The terms used are listed in the text but specific search strategies are not included.
What criteria were used to decide on which studies to include?
Empirical and observational studies in children and adults with intellectual disabilities and any physical medical condition that reported problem behaviour outcomes were eligible for inclusion. All levels of intellectual disability were allowed. Studies with fewer than five participants were excluded, as were those focusing on medication side effects, substance abuse, and specific syndrome phenotypes. Challenging behaviour was defined according to the ‘Diagnostic criteria for psychiatric disorders for use with adults with learning disabilities (DC-LD)’, axis III, level D. Problematic feeding disorders were also included in the study definition. Studies published in English, Dutch and German were considered.
Who decided on their relevance and quality?
One named author screened the titles and abstracts for relevance after which the full texts of potentially relevant studies were obtained. Two reviewers assessed the studies and a third was available to make a decision if an agreement could not be reached. Study quality was measured using the SIGN criteria which assign eight levels of evidence ranging from 1++, for high-quality randomised controlled trials, to 4 for expert opinions.
How many studies were included and where were they from?
Forty-five studies were selected for inclusion; the total number of articles retrieved from the search is not reported, nor is the number of exclusions. There is no indication of the study settings.
How were the study findings combined?
Study characteristics and outcomes were analysed by two of the authors and are reported in Tables 3 to 10, along with the levels of evidence. The studies were allocated to one of eight categories: general physical conditions, motor disorders, sensory impairment, epilepsy, gastrointestinal disease, sleep disorders, dementia, and ‘other’. The review is narrative in nature.
Findings of the review
The number of studies for each category of physical disorder was: general medical conditions 14; sensory impairment 3; epilepsy 8; gastrointestinal disorders 8; sleep disorders 7; dementia 2, and; ‘other’ 3. There were 11 well-conducted studies, four rated 2++ and seven rated 2+, which revealed significant and independent associations between challenging behaviour and urinary incontinence, pain related to cerebral palsy, and chronic sleep problems. A significant association was found between visual impairment and self-injurious behaviour, but not with aggressive behaviour. There was no evidence of a significant association with hearing impairment, bowel incontinence, mobility impairment, or epilepsy.
Results from the remaining 21 poor-quality analytical studies, and the 13 non-analytical studies suggest that there may be an association between gastro-oesophageal reflux disease, dysphagia, dementia, menstrual cycle phases, and specific subtypes of epilepsy.
Authors' conclusions
‘The present review highlights the role that medical conditions can play in challenging behaviour and the need for evaluating those conditions in clinical practice. It also reveals major gaps in the evidence, because many studies are of low quality and many physical illnesses have not been investigated.’
Implications for policy or practice
Some suggestions for clinical practice are made but these are based on limited evidence.