Challenging Behaviour

1
Challenging Behaviour Mental Health
Prevention, Early Intervention Ongoing
Support

• Eric Emerson
• Institute for Health Research
• Lancaster University

2
The Plan

• Summarise the evidence
• 10 things we know .
• Implications
• Prevention
• Early intervention
• Ongoing support

3
Ten Things We Know .

• Many people with intellectual disabilities have
  significant challenging behaviours or diagnosable
  mental health problems

4
Prevalence

• Challenging behaviour
• 5-15 of service users
• 25-75 people per 100,000
• 1,000-3,000 per 4 million

• Mental health
• Children
• 40 of children with intellectual disabilities
  have diagnosable mental health problem
• 10 of all children who have diagnosable mental
  health problem have intellectual disabilities
• Adults?

5
Ten Things We Know .

• Many people with intellectual disabilities have
  significant challenging behaviours or diagnosable
  mental health problems
• Need is inequitably distributed

6
The Geography of Need

• Social deprivation is associated with
  significantly increased risk of
• (Less severe) intellectual disability
• Challenging behaviour/mental health
• In 1999, 60 of British children with
  intellectual disabilities and a diagnosable
  mental health problem were living in poverty

7
Household Income Risk of Child Mental Health
Problems in Britain
8
The Geography of Need

• Social deprivation is associated with
  significantly increased risk of
• (Less severe) intellectual disability
• Challenging behaviour/mental health
• In 1999, 60 of British children with
  intellectual disabilities and a diagnosable
  mental health problem were living in poverty

9
The Goals of Health Policy

• Health gain
• Health equity
• The highest attainable standard of health should
  be within reach of all 'without distinction for
  race, religion, political belief, economic or
  social condition' (1998 World Health Declaration)

10
Ten Things We Know .

• Many people with intellectual disabilities have
  significant challenging behaviours or diagnosable
  mental health problems
• Need is inequitably distributed
• People do not grow out of these problems

11
Ten Things We Know .

• Many people with intellectual disabilities have
  significant challenging behaviours or diagnosable
  mental health problems
• Need is inequitably distributed
• People do not grow out of these problems
• There are very significant costs associated with
  these problems

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Ten Things We Know

• The factors causing /or maintaining challenging
  behaviour/mental health problems are varied and
  complex
• Biological
• Genetics, neurobiological medical/psychiatric
  processes
• Social
• Psychological/behavioural processes
• Control power (communication)

13
Ten Things We Know

• Some approaches to intervention can work
• Positive behavioural approaches
• Some drugs
• Some do not
• Semi-detached housing therapy
• Some drugs

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Ten Things We Know

1. Intervening in adulthood is tough .
2. and difficult to sustain
3. Most people with significant levels of need do
   not get access to evidence-based support

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Checklist

• Coverage?
• Equitable?
• Longer-term commitment?
• Range of expertise?

• Individualised?
• Contextualised?
• Evidence-based?
• Effectively monitored managed?

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Main Implication .

• The importance of adopting a more public health
  perspective
• Invest in prevention and early intervention
• The case for prevention and early intervention
• The viability of therapeutic models

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The Case for Prevention Early Intervention

• Efficiency
• Best use of resources
• Evidence
• Generic (direct)
• Specific (but indirect)

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The Viability of the Therapeutic Model

• Interventions, therapies and therapists are
  unlikely to solve the problem
• Capacity to deliver interventions at an
  appropriate scale
• Effectiveness of current and future therapies
• Growing need/demand

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A Comprehensive Strategy

• Prevention
• Early intervention
• Ongoing support (technical, practical
  emotional)
• For people with intellectual disabilities
• For carers

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Social Determinants of Health
Accumulated Risk of Exposure Across the
Lifecourse Physical Hazards (cold/damp
housing, air pollution, toxins, accidents,
nutrition arduous work) Psychosocial
Hazards (low status control,
uncertainty, life events)
SEP
Health Status
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Social Determinants of Health
Accumulated Risk of Exposure Across the
Lifecourse Physical Hazards (cold/damp
housing, air pollution, toxins, accidents,
nutrition arduous work) Psychosocial
Hazards (low status control,
uncertainty, life events)
Vulnerability Resilience Biological (embedded
organ weaknesses, fitness) Psychosocial (human
capital, social affiliations social
capital) Health Care (including prevention)
SEP
Health Status
22
Prevention

• Universal and targeted interventions to ..
• Reduce exposure to potential material
  psychosocial hazards

• General risk reduction
• Poverty reduction
• Reducing risk in neighbourhoods communities
• Specific risk reduction
• Child protection
• Improving parenting

23
British Medical Association Guidance

• The reforms outlined in the Child Poverty Review
  must be implemented to end child deprivation and
  therefore reduce risk factors for mental health
  problems.
• BMA (June 2006)

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Prevention

• Universal and targeted interventions to ..
• Reduce exposure to potential material
  psychosocial hazards
• Reduce vulnerability and promote resilience

• General risk reduction
• Poverty reduction
• Reducing risk in neighbourhoods communities
• Specific risk reduction
• Child protection
• Improving parenting

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Some Aspects of Resilience

• Nurturing, affectionate and secure relationships
  with one parent
• Supportive relationship with one other adult
• Positive, rewarding school environments
• Positive personal achievements
• Sense of connectedness to the school and/or
  local community
• Involvement in pro-social peer groups

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Early Intervention

• Extensive (but indirect) evidence of efficiency
• Effective programmes
• begin early
• offer intense support
• intervene directly with the child family
• are comprehensive and flexible
• need to be long-term
• are effectively targeted
• take account of family circumstances

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Pieces of the Jigsaw

• Prevention
• Early identification and intervention
• Ongoing support
• Development delivery of interventions
• Practical emotional support
• Effective management

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Some Issues .

• Congregate or non-congregate services?
• Role of Assessment Treatment Units?
• Separating out support and intervention functions
• Strengthening supporting the commissioning of
  local options (SCIE)
• Workforce planning
• Regulation performance management
• Person-centred solutions

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• Copy of the slides ..
• eric.emerson_at_lancaster.ac.uk