CNSDrugs2009:2301):903^13

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2009 Adis Data Information BV. All rights reserved.

Aggressive Behaviour in Adults with

Intellectual Disability
Defining the Role of Drug Treatment
Patricia Oliver-Africano,^ Declan Murphy^ and Peter Tyrer^
1 Imperial College London, London, UK
2 Institute of Psychiatry, London, UK

Abstf act A complex form of aggression, commonly expanded as 'aggressive challeng-

ing behaviour', is reported in one in four adults with intellectual disability
and is often treated with antipsychotics, mood stabilizers and antidepressants.
Psychological treatments, including anger and behavioural management,
person-centred planning and manipulation of the environment (nidotherapy),
have also been used when available but to a lesser extent. In this article, the
evidence for efficacy for each intervention is examined, with data from ran-
domized controlled trials given primacy. Very little evidence, based on limited
data, can be found for the interventions of anger and behavioural management
and also for the atypical antipsychotic drug, risperidone; the data available
on these interventions come primarily from studies conducted in children in
whom the behaviour is part of the autistic spectrum. Antipsychotic drugs,
particularly the atypical group, have been the most commonly used interven-
tions in recent years, but a recent independent randomized trial showed no
benefits for either risperidone or haloperidol compared with placebo, with some
evidence of a better response to placebo than either active drug in the reduction
of aggression.
In the light of this uncertainty, the clinician must return to the task of
collecting a careful history and mental state examination, including aware-
ness of the setting in which the behaviour is shown, which will help with
diagnosis and appropriate intervention. The choice of intervention should
pot be a casual one and is not likely to be chosen well if the clinician relies only
on standard guidelines.
The paucity of randomized trial evidence is preventing progress in the
treatment of persistent aggressive behaviour. On present evidence, the use of
drug treatment should be much more sparing and reserved for those patients
who are putting themselves and others at particular risk as a consequence of
their behaviour; such treatment should be regarded as temporary and as ad-
junctive to other forms of management. There is an urgent need for larger,
randomized studies of psychological interventions, which at present appear to
have a higher benefit-risk ratio than drug treatment but that also have a poor
evidence base. More care should be taken to avoid the term 'aggressive chal-
lenging behaviour' being used as a portmanteau diagnostic pseudonym when it
. merely represents a diverse oppositional repertoire of many aetiologies.
904
Persistent behavioural problems are common
in many disorders, but even when these are all
taken into account, there remains a core of be-
havioural problems that goes beyond the specific
diagnostic conditions concerned. Many inter-
ventions for persistent behavioural problems are
for people with intellectual disability, which, de-
spite its importance, has a relatively low evidence
base for interventions.^''
'Challenging behaviour', often expanded to
'aggressive challenging behaviour,' is the term
used to describe behaviour problems of people
with intellectual disability. It does not have a
simple equivalent in general adult psychiatry but
is recognized in the behavioural problems of
older people, particularly when cognitive func-
tion is impaired, and in people with intellectual
disability, dementia may present in a similar
manner.t^l Technically, the term refers to behav-
iours that challenge services, i.e. any behaviour
that is socially unacceptable. However, its major
consequence is that individuals who repeatedly
show this behaviour are likely to be taken out of
community settings and put into more institu-
tional ones, and this has important clinical and
cost consequences. For the purposes of this article
we will confine ourselves to the epidemiology and
management of persistent aggressive behaviour.
In people with intellectual disability, persistent
aggressive behaviour is quite different from simi-
lar behaviour seen in other conditions, for ex-
ample, in antisocial personality disorder. Patients
with intellectual impairment are often unaware of
social conventions and so may behave inappro-
priately in social settings. At other times these
behaviours represent aspects of elevated or de-
pressed mood, distress or anger. Such behaviour
is formally defined as "any culturally abnormal
behaviour(s) of such intensity, frequency or
duration that the physical safety of the person or
others is likely to be placed in serious jeopardy, or
behaviour which is likely to seriously limit use of,
or result in the person being denied access to,
ordinary community facilities."t^'
Aggressive behaviours are subsumed in a group
of disorders in people with intellectual disability
that are not formal diagnoses but are clearly re-
cognized and may often be manifest without any
2009 Adis Data Information BV. Allrightsreserved.
Oliver-Africano et al.
other formal diagnosis being present.t'I However,
in most studies of children, a formal diagnosis has
been present.
Functional analysis is often used to assess the
likely causes of these behaviours.''I This involves
careful observation of the person concerned over
a period of time, at least 24-48 hours, so that the
relationship of antecedent conditions and the
consequences of behaviour can be determined.t"*'^'
This is important, as the management of an indi-
vidual who behaves in an inappropriate way be-
cause of over-stimulation is very different from
that of a bored individual who wishes for excite-
ment. It is also important to distinguish episodic
behaviours that result from environmental fac-
tors from more persistent behaviours that are
long standing and often represent learned behav-
iours. People in this latter group bear some
resemblance to those of normal intelligence
who have Cluster B personality disorders.''^
1. Epidemiology
An influential Cochrane review has shown
that significant behavioural problems and psy-
chiatric disorders are common among people
with intellectual disability throughout their life-
span.t^l These rates vary widely, but the point
prevalence is approximately 18-23% in the com-
munity.t^'^1 Even in settings where a minority of
people are showing persistent aggressive behav-
iour, it has an effect on approximately half of the
others living in the same setting.^' It is disturbing
that more than one-quarter of all mental illness in
the intelectually disabled is accounted for by this
disorder in the absence of any other pathology.'"*!
In children, it has been estimated that 4.5% of
those with intellectual disability show similar
behaviours.'"'
Some 10-15% of adults with intellectual dis-
ability in contact with services exhibit aggres-
sive behaviour,''^' with increasing proportions in
those with more severe disability.''^' The range of
persistent aggressive behaviour is very wide and,
in addition to verbal and physical aggression,
includes temper tantrums, unwanted sexual con-
tact (hypersexualism), destruction of property
CNSDajgs2009;23(n)
Aggressive Behaviour in Intellectual Disability
and self-injury. Assessment of personality status
is seldom made in the intellectual disability
population and, since the prevalence of such
personality disorders varies from <1% to 91% in a
community setting and 22-92% in hospital set-
tings,t''*l the value of a personality disorder diag-
nosis is dubious.
Since one-quarter to one-half of all people
with intellectual disability in community settings
and >50% of those in hospitals exhibit aggressive
challenging behaviour at some time in their lives,
the public health importance of this subject is
considerable.t''-'^' Drug treatment is frequently
prescribed on a regular basis for people with
intellectual disability and persistent aggressive be-
haviour, with 22-45% of patients in hospital and
approximately 20% of patients in the community
receiving antipsychotic medication.t'^"'^! With
the relocation of people with intellectual dis-
ability into the community, the use of these drugs
is now spread over a larger number of settings.
2. Management and Treatment
To identify the treatments used for persistent
aggressive behaviour in adults with intellectual
disability, a search was made of the Cochrane
Database of Systematic Reviews and the PubMed
database using the terms 'treatment', 'aggression',
'aggressive challenging behaviour' and 'mental
handicap/learning disability/intellectual disability'
in English language publications between January
1980 and July 2008. This revealed 184 papers, but,
although many interventions have been described,
only antipsychotic drugs, mood stabilizers, selec-
tive serotonin reuptake inhibitors (SSRIs), anger
management and behaviour therapy have been
subjected to formal evaluation; this includes eight
randomized trials and one meta-analysis. The
findings of these studies are summarized in table I.
Other treatments, including benzodiazepines,
person-centred planning, environmental manip-
ulation and music therapy, are widely used and so
are also included in table I.
The most commonly described treatments for
persistent aggressive behaviour in people with
intellectual disability are atypical antipsychotic
drugs (as described in section 1), general environ-
2009 Adis Data Information BV. All rights reserved.
905
mental management strategies and a range of
psychological treatments, with wide variation in
their degree of evaluation. Intellectual disability
is not an area in which there is a great deal of
evidence about the efficacy of interventions,
largely because of the difficulties in carrying out
randomized controlled trials (RCTs) in people
with significant intellectual impairment.t'*^-''*!
Most of the relevant studies have been carried out
in people with behavioural problems as it is these
that present the greatest problems in management.
The treatment of persistent behavioural pro-
blems is usually lengthy, eventful and frustrating
for both therapists and patients. Successful
engagement requires commitment and persever-
ance, and although the therapist often hopes that
any abnormal behaviour is a consequence of the
disorder being treated by evidence-based thera-
pies and should, therefore, improve along with
other symptoms, all too often the behavioural
difficulties persist independently.^''
3. Psychopharmacologicai Treatment
Drug treatment has been used for many years
in people with intellectual disability who show
behavioural problems and is usually, if not always
appropriately, the first choice of management.
In the first half of the last century, the choice
of treatment included bromides, barbiturates and
antihistamines; more recently, antipsychotic drugs,
mood stabilizers and SSRIs have been used.t'l
3.1 Antipsychotic Drugs
As noted in section 1, antipsychotic drugs are
regularly prescribed for people with intellectual
disability. Most early studies on the treatment of
aggressive behaviour in intellectual disability
were carried out with typical antipsychotic drugs
such as haloperidol. However, these drugs have a
high incidence of extrapyramidal adverse effects,
including acute dystonias, which has inhibited
their use and led to a gradual switch to the newer
atypical antipsychotic drugs. This change now
appears to have been made in error, as the higher
incidence of movement disorders is only found
with a minority of typical antipsychotic drugs in
CNS Drugs 2009,- 23 (11)
906 Oliver-Africano et al.

Table I. Summary of treatments available and evidence for effectiveness for the treatment of aggressive behaviour in inteliectuai disabiiity
(from search strategy described in section 2). Only studies in adults with inteliectuai disabiiity are included here
Treatment Form of No. of Levei of evidence for efficacy Comments
treatment papers
[reference]
Antipsychotics
clozapine Orai . 1118] Open-labei trial of effectiveness oniy
zuciopenthixoi Orai 1(191 Discontinuation trial oniy
olanzapine Orai I [20]
Open-label triai oniy
risperldone Orai 4121-24)
Three randomized trials with The only independent trial in aduits showed no
confiicting resuits effect but this trial had more patients with
severe disabiiity.^*' One of the other
independent triais (in chiidren, adoiescents
and aduits) had positive effects'^^l
Seiective serotonin Oral 3125-271 Open-iabei or retrospective triais
reuptai(e inhibitors only, apart from McDougie et al.,'^^1
(SSRIs) which was a randomized controiied
trial
Mood stabiiizers
lithium Orai 2P8.29]
Two randomized inpatient triais, Both triais had a placebo run-in before
one industry sponsoredi^^' randomization but showed benefit with lithium
(Regan, personal communication), treatment
the other noti^
Benzodiazepines Orai/ 1(17) Clinical opinion only Wideiy used, without good evidence
injectable
Anger management Group 2(30.311 Two randomized trials Both triais are encouraging and have led
to a large, funded, randomized trial with
Prof. P. Wiliner as principal investigator
(HTA 08/53/34, UKCRN ID 7089P2J)
Behavioural therapy Individuai 6(33-381
Meta-anaiysis Although evidence derives from a meta-
(including functionai analysis, this was of single case studies only
communication
training)
Cognitive behaviourai Individual/group 1(391
Descriptive study oniy Wideiy used, but not yet properly adapted for
therapy this popuiation
Person-centred Individuai 1(401
Ciinicai opinion only Wideiy used, but no formal testing
pianning
Environmental 3[41-43)
Individual/group Ciinicai opinion only As persistent aggression in many with severe
manipuiation inteliectuai disabiiity may be very dependent
(nidotherapy) on the environment, this approach is
understandabie despite no formai evaiuation
Music therapy and Individuai and 3144-46]
Open studies oniy Widely used, but needs formai evaiuation
controiied group
muitisensory
stimuiation

The extent of use of antipsychotic drugs in no evidence as to whether antipsychotic medica-

intellectual disability is considerable. A systema-
tic review in 2007'^! found over 500 citations to
this treatment, but only eight RCTs in adults
could be included in this analysis. The same
authors' conclusion following a systematic review
of RCTs in 1999 was that "these trials provided
tion does or does not help adults with intellectual
disability and aggressive behaviour."[^l Today
this might not be stated quite so negatively, but it
is a very unsatisfactory evidence base for a com-
mon treatment. A similar review published in
2006 came to a similar conclusion and urged the

2009 Adis Data (nformation BV. All rights reserved. CNS Drugs 2009: 23 (11)
Aggressive Behaviour in Intellectual Disability
need for better RCTs.t^'l What is also alarming is
that many clinicians use these medications long
term without ever giving patients a trial without
therapy, even though approximately one in three
individuals in one study were able to reduce treat-
ment by gradual taper and then stop treatment
without problems.t^^l
Until recently, almost all trials of anti-
psychotic drugs in intellectual disability were
industry-funded ones. Some of these have been
very sound, others much less so, but what is
incontrovertible is that studies that are funded by
industry are much more likely to show positive
results than those that are independent.t^^'^"'
Therefore, in a situation where all positive trials
have been funded by industry, it is reasonable to
be sceptical about the conclusions.
Van den Borre et al.'^'l carried out an early,
complicated, crossover trial involving the admin-
istration of risperidone (4-12 mg daily) or placebo
added to existing medication for 3 weeks, followed
by placebo washout for 1 week, and then another
3 weeks' treatment using the alternative crossover
medication. Thirty-seven patients were recruited
and 30 finished the study. The results suggested a
positive effect with risperidone but were com-
pletely compromised by differing results in the
crossover arms, a common problem when there
are carryover effects from one treatment to an-
other. Indeed, the duration of pharmacodynamic
effects of antipsychotic drugs is so great that
crossover trials, despite their attractions for re-
searchers who anticipate low patient numbers, are
not, in the opinion of these reviewers, appropriate
for therapeutic studies with these drugs.
Buitelaar et al.t^^' also examined the efficacy of
risperidone in a 6-week, randomized, double-
blind, parallel-group study of the treatment of
aggression in 38 hospitalized adolescents with
mild, borderline intellectual disability, some
within the normal range of intelligence, who had a
primary diagnosis of DSM-IV disruptive behav-
iour disorders. Risperidone, at a mean daily dose
of <3mg, was associated with significant im-
provement in, severity of illness and behaviour
disturbance. Hellings et al.'^^l found similar results
in a crossover study in children, adolescents and
adults who were predominantly within the autistic
2009 AdIs Data Informotian BV. All rights reserved.
907
^i Gagiano et al.^^l compared risper-
idone (1-4 mg daily, mean 1.45mg/day) with pla-
cebo in 77 patients with intellectual disability
(including 18% with borderline intelligence in the
risperidone group) over a 4-week period after a
placebo run-in period in a randomized, double-
blind trial, with outcome determined primarily by
the Aberrant Behavior Checklist.I^^l Patients tak-
ing risperidone improved by 22% more than those
allocated to placebo (p<0.04), but those receiving
placebo improved by 31%, showing the extent of
non-specific factors in the treatment of aggressive
behaviour. Irritability was the first symptom to
show differential improvement with risperidone,
as early as 2 weeks after starting therapy.t^^'
Risperidone is now widely used in intellectual
disability units in the UK, where it is often as-
sumed to be the standard accepted treatment
despite not being licensed for this condition and
with no evidence of any superiority over other
antipsychotic drugs of any type.''!
The position of antipsychotic drugs in the
treatment of children with aggression and disrup-
tive behaviour is a more robust one. There have
now been several randomized trials with partici-
pant numbers varying from 38 to 118, mainly with
risperidone, that have shown benefits in hospi-
talized adolescents,^^^' disruptive children with
autism and intellectual disability,'^*' and autistic
children (aged 5-17 years) with severely challeng-
ing behaviours and intellectual disability.'^''*"'
Although these studies showed benefit in terms of
symptoms, weight gain was also noted in those
who took the active drug. There have been no
comparative studies in which the effects of more
than one antipsychotic drug have been evaluated
in a randomized trial and so the choice of risper-
idone for this purpose is made in the absence
of information on competitors. The effect size
was largest in the sample of autistic children;'^''
however, it should be noted that all of these chil-
dren had a clear diagnosis in the autism spectrum.
This differs from the studies in adults, as many of
these patients do not have a formal psychiatric
diagnosis.
More recently, a discontinuation study with
zuclopenthixol in adults with intellectual dis-
abilityl'^1 showed possible benefits of the drug
CNS Drugs 2009: 23 (11)
908
but only in terms of maintaining improvement
after treatment. In those patients with intellectual
disability and aggressive behaviour who had
improved after initial treatment, withdrawal of
the active drug was followed by a worse out-
come in those randomized to placebo than in
patients randomized to continue zuclopenthixol.
However, it would be mistake to assume that a
discontinuation study in itself is indicative of
efficacy.^''
In 2008, the independently funded trial from
the Health Technology Programme of the De-
partment of Health in the UK, NACHBID
(Neuroleptics in Adults with Aggressive Chal-
lenging Behaviour and Intellectual Disability),!^'*!
was completed. This three-arm, parallel-design
trial (risperidone vs haloperidol vs placebo) was
initiated to explore and extend the evidence base
for the effectiveness of antipsychotic medication
in the management of a representative sample of
adults with intellectual disability and aggressive
behaviour across sites in the UK and Australia.
The results showed a reduction in aggression at
4 weeks (the primary outcome chosen in ad-
vance), with placebo showing the greatest change
when compared with the typical antipsychotic
haloperidol and atypical antipsychotic risperidone.
The authors concluded by cautioning against the
use of antipsychotic drugs in the routine treatment
of aggressive behaviour in this population.P"*'
3.2 Mood Stobilizers
Two randomized trials^^'^^' have been carried
out with lithium in the treatment of aggressive
behaviour in intellectual disability. Tyrer et al.P^'
treated 25 inpatient adults with intellectual dis-
ability and persistent aggressive behaviour in a
double-blind crossover trial lasting 5 months that
compared the effects of lithium with placebo on
aspects of aggressive behaviour. All patients were
receiving antipsychotic and/or antiepileptic
drugs, which were continued during the trial.
Seventeen of the patients showed greater im-
provement with the lithium phase of treatment
than with placebo. Craft et al.,^'' in a parallel-
group industry-funded trial lasting 4 months and
involving 42 intellectually disabled patients,
2009 Adis Data Informatian BV. All rights reserved.
Oliver-Africano et al.
compared aggression in patients randomized to
receive lithium or placebo. In the lithium-treated
group, 73% of patients showed a reduction in
aggression during treatment and somewhat bet-
ter scores than patients receiving placebo.
Although neither of these studies used an ac-
cepted scale to record aggressive behaviour, no
agreed instrument was available at the time and
this was not considered a major problem in design.
The results persuaded the Committee on Safety of
Medicines to license lithium for the treatment of
aggression in this population. Despite this, the
drug is not widely employed in practice.^''
Topiramate, an antiepileptic drug, has also
shown promise but only in open-label trials.!^''
Other antiepileptic drugs, including carbamaze-
pine and sodium valproate, have also been
used, but the evidence for their use comes from
single case reports
3.3 Selective Serotonin Reuptake Inhibitors
(SSRIs) and Benzodiazepines
Although SSRIs have been used repeatedly
for the treatment of aggressive challenging be-
haviour, there have been no adequate trials of
effectiveness and the evidence is circumstantial
or based on simple open-label studies (e.g.
Janowsky et al.t-^^'). The positive findings of
benefit from these drug company-sponsored stu-
dies have to be offset against a case-note study of
Branford et al.,^^^' which concluded that there
was no clear benefit for these drugs because,
although there was some improvement in 13 of
37 (35%) patients treated, they were of no benefit
in 15 (41%) other patients and led to a deteriora-
tion in a further 9 patients (24%).['i However, an
RCT in patients with adult autistic disorder
showed that fiuvoxamine was significantly better
than placebo in reducing aggression (p<0.03)
and also showed superiority for other symptoms
Benzodiazepines have also been used fre-
quently in the treatment of aggressive challenging
behaviour, often in combination with other
drugs,[^^' but are generally discouraged for this
purpose and have not been subjected to con-
trolled evaluation.
CNS Drugs 2009:23 (11)
Aggressive Behaviour in Intellectual Disability 909

4. Psychological Treatments meta-analysis of all studies between 1976 and

1987 found serious deficiencies with the method-
4.1 Anger Management ology of most of the investigations.t^^' These
authors concluded that "the results largely failed
That it is feasible to conduct RCTs of more
to support several widespread assumptions re-
conventional psychological interventions has been
garding precepts of clinical practice."
demonstrated by two recent RCTs of anger man-
A form of differential reinforcement of other
agement that were conducted amongst people with
behaviour has been recently proposed that is
intellectual disabilities living in secure settings'^'
termed 'functional communication'.I^'*' This term
and in the community .f^'' Both of these studies used
refers to an approach to help alter inappropriate
randomized allocation either to a waiting list con-
behaviour by encouraging the individual to com-
trol group or to a group treated over 12 or 9 weeks,
municate his or her wishes in an acceptable way
respectively, including both self-management and
with appropriate reward. This is carried out by
cognitive techniques. The study of offenders with
reinforcing all efforts by the person undergoing
intellectual disabilities^"^ reported significant im-
scrutiny to indicate his or her feelings in a non-
provements in anger control in the treated group, as
challenging way. Most studies in this area have
assessed by participants' self-reports. Staff ratings
been performed in small samples, but some studies
of participants' anger showed similar gains, but the
have shown encouraging effects.'^^' Furthermore,
effect was not statistically significant; however, staff
in a meta-analysis of single-subject research stu-
rated participants' behaviour on the ward as sig-
dies (which are particularly prone to publication
nificantly improved post-treatment and at 1-month
bias), choice making as an intervention was
follow-up. In the community study,t^'l the treated
shown to be effective in improving behaviour.I^'l
group improved significantly relative to the con-
A very recent randomized trial has added mark-
trol group and to their own pre-treatment scores,
edly to the evidence for structured team-based
as assessed by participants' self-ratings and by
behaviour therapy by showing clear benefits
carer ratings. These gains were maintained at
compared with standard t^^^
3-month I^'l
4.3 Cognitive Behaviourai Therapy
4.2 Behavioural Therapy
Although cognitive behavioural therapy has
Standard behavioural techniques based on op-
been adapted across the field of intellectual dis-
erant conditioning were once extremely commonly
ability, it has less evidence supporting it than in
used in institutions for people with intellectual
most other psychiatric disorders, largely because
disability. These included common behavioural
of the absence of controlled trials. However, the
approaches such as 'time out' (removal of the
idea that cognitive behavioural therapy is not
person to an environment lacking the possibility
suitable for those with limited intelligence is not
of social reinforcement), seclusion,'^^' over-
an adequate reason for failing to employ this mode
correction and physical restraint. These are often
of therapy, and failure to consider it is said to be
referred to as aversive treatments, sometimes er-
misplaced.t-'^l However, only anger management,
roneously. Alternative conditioning techniques
an intervention that adopts some of the principles
involving positive reinforcement following the
of both cognitive and behavioural approaches,
general principles of contingency management
has been formally evaluated and is sufficiently
are now more commonly used for drug misuse.^^^'
distinct to be considered separately.
There is also a distinction between differential
reinforcement of other behaviour and differential 4.4 Person-Centred Pianning
reinforcement of incompatible behaviour. Most
of the evidence for the success of these last two Person-centred planning has been introduced
approaches is found with stereotypical behaviour in the management of people with intellectual
''l but the evidence base is very slim and a disability in an attempt to give greater power to

2009 Adis Data Information BV. All rights reserved. CNS Drugs 2009:23 (11)
910
them by a combination of promoting increased
choice, listening more to their needs and wishes,
building relationships and promoting better sup-
port systems.t'*^^ Although widely used, it has not
been evaluated using controlled investigations
and there is a lack of studies of this approach in
aggressive challenging behaviour.
4.5 Environmental Manipulation
(Nidotherapy)
Nidotherapy is a "collaborative treatment in-
volving the systematic assessment and modification
of the environment to minimise the impact of any
form of mental disorder on the individual or on
society."[^^ It is based on Charles Darwin's original
emphasis in his theory of evolution on the 'survival
of the adapted' (subsequently renamed by the psy-
chologist Herbert Spencer as 'survival of the fit-
test'). The notion of improving the adaptation of
people to suitable environments rather than trying
to change them to be different transfers the empha-
sis on change in the person to change in the environ-
ment. This is highly relevant to intellectual disability
and the advantages of harnessing environmental
changes have been noted.f'*''^^'^ However, although
a cluster randomized trial of its effectiveness in ag-
gressive challenging behaviour is currently being
carried out (NIDABID: Nidotherapy for Aggressive
Behaviour in Intellectual Disability), there is, as yet,
no published evidence supporting its efFicacy. How-
ever, in the authors' experience it is well received and
very easy to administer.
Among other therapies likely to be of benefit
but with no formal evaluation, music therapy
appears one of the most promising.t'*^'
4.6 Summary
A 2004 review of psychological interventions for
aggressive behaviour in intellectual disabilityt^^
found only three trials suitable for inclusion in its
analysis and concluded that "direct interventions
based on cognitive-behavioural methods (modified
relaxation, assertiveness training with problem solv-
ing, and anger management) appear to have some
impact on reduction of aggressive behaviour at
the end of treatment but not at follow-up (up to
6 months), as rated by individuals and their car-
2009 Adis Data Information BV. All rights reserved.
Oliver-Africano et al.
ers." An update of this review!^*' has concluded
"The existing evidence on the efficacy of cogni-
tive behavioural and behavioural interventions
on outwardly directed aggression in children and
adults with learning disabilities is scant."
5. Conclusion
On the basis of current evidence, the pre-
eminence of drug treatment in the treatment of
aggressive challenging behaviour in people with
intellectual disability is now being challenged,!^^^
but this does not mean that other forms of treat-
ment, such as psychological treatments, should
be preferred. One of the main problems is that
diagnostic practice is still poor in the area of in-
tellectual disability, and therefore many patients
may be being treated inappropriately. Some may
not merit any diagnosis because aggressive chal-
lenging behaviour may be within the range of
normative reactions, and the behaviour of other
individuals may be misdiagnosed as that of a
psychosis, without recognition that intellectual
disability is present.t^^^
We also need a much bigger evidence base for
each intervention, no matter what type, so that all
treatments are subjected to much greater scru-
tiny, and also to recognise the truth of the mantra
'absence of evidence is not evidence of absence'.
Despite the paucity of good evidence, we are
moving slowly in the right direction, even though
an informed guide to the treatments currently
available is like being led in a country of the blind
and deaf by someone who only has a mobile
phone.
Acknowledgements
The authors were supported by the National Coordinating
Centre for Health Technology Assessment (NCCHTA),
Southampton, UK, in their funding of the NACHBID (Neuro-
leptics in Adults with Aggressive Challenging Behaviour and
Intellectual Disability) trial mentioned in this review. The
views expressed are those of the authors alone. We thank
Anna Maratos, Stephen Tyrer, Adrienne Regan and Freya
Tyrer for providing data and comments in the preparation of
this paper. Dr Oliver-Africano has acted as a consultant for
Maitland in analyzing the resource use of individuals with a
developmental disability in Ontario for the Client Ministry of
CNS Drugs 2009; 23 (11)
Aggressive Behaviour in Intellectual Disability
Community and Social Services, Ontario, Canada. Drs Tyrer
and Murphy have no conflicts of interest that are directly
relevant to the content of this review.
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Correspondence: Prof. Peter Tyrer, Department of Psycho-
logical Medicine, Imperial College, St Dunstan's Road,
London W6 8RP, UK.
E-mail: p.tyrer@imperial.ac.uk
CNS Drugs 2009; 23 (11)
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