Friends of the Forensic Science Blog, this week we present the paper “Aggressive challenging behavior in adults with intellectual disability: An electronic register-based cohort study of clinical outcome and service use”, by Smith, J.; Baksh, R. A.; Hassiotis, A.; Sheehan, R.; Ke, C.; Wong, T. L. B.; Strydom, A. and PETAL investigators (2022), in which authors compiled information about patients with intellectual disability to know better how aggressive defiant behavior is presented in this population.
Intellectual disability is a lifelong condition, characterized by impaired cognition, language and social skills, affecting approximately 1% of the world’s population.
Challenging behavior, which includes self-injury, aggression, threats, physical violence, and sexually aggressive behavior, among others, is estimated to have a prevalence of approximately 10% among adults with intellectual disability, and tends to persist over time, with a rate of approximately 25% at 2 years.
Aggressive challenging behavior is a common reason for referral of adults with intellectual disabilities to health services, and can have serious consequences, from family and caregiver stress to contact of the person with the disability with the criminal justice system.
Some previous studies that have explored factors associated with aggressive challenging behavior in adults with intellectual disabilities have shown that male gender, some comorbid autism spectrum disorder, communication problems, and disability aggravation are associated with higher levels of aggression.
The authors’ aim in this study was to update the available information on factors associated with aggressive challenging behavior in adults with intellectual disabilities.
To this end, data from the South London and Maudsley (SLaM) National Health Service (NHS) Foundation Trust in the United Kingdom were considered. SLaM is one of the largest providers of mental health care in the European area.
Data from patients older than 18 years old were considered. These had to have had an episode of outpatient care that included direct contact with a team specializing in mental health, more specifically, intellectual disability, all between January 2014 and December 2018. There were a total of 1,225 patient records analyzed.
Some of the most interesting insights the study yielded was that episodes with high frequency of aggression were of longer duration than those episodes with lower frequency (over 2 years vs. approximately 4 months).
Younger adults, mean age approximately 31 years, had a higher frequency of episodes of aggression.
Mood instability, irritability, and agitation were strongly associated with a higher occurrence of aggressive defiant behaviors.
Nearly 60% of the patients had at some point a diagnosis of pervasive developmental disorder.
Authors found that aggressive challenging behavior occurs in the majority of clinical care episodes requiring the involvement of a specialized intellectual disability health care team.
It appears that, as discussed above, being younger, having a diagnosis of pervasive developmental disorder, and mood instability and irritability all play a role and are risk factors.
Other risk factors included the presence of a common mental disorder, personality disorders, and agitation during aggressive episodes.
The amount of social and health care provided, although very important for families, did not really prove to be a risk factor.
A very important point made by the authors, is that mental illness or mental health problems are often not diagnosed in people with disabilities because of atypical behavioral manifestations that already exist. That is, some behaviors that may inform a mental disorder are taken to be consequences of intellectual disability. Therefore, there is a high level of diagnostic uncertainty.
In a recent study based on a group of 142 people with intellectual disabilities, it was shown that almost one third of the participants had some type of undiagnosed mental health problem, with major depressive and anxiety disorders being the most common.
Authors point out the importance of devoting efforts and resources to research on people with intellectual disabilities, first, to understand the health condition with which they live and, second, to help bring their quality of life as close as possible to that of those with typical intellectual development.
In addition, understanding why aggressive behaviors arise would help not only these individuals but also their environment and interpersonal relationships, which would gain stability and quality.
It is important to consider aggressive challenging behavior as a public health problem that needs more research and clinical investment, as well as more effective forms of individualized intervention and support.
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