Psych · Intellectual disability psychiatry
Challenging behaviour and positive behaviour support
Also known as Behaviours that challenge · Behaviour of concern · Problem behaviour · Positive behavioural support · PBS · Functional behaviour assessment · Challenging behavior intellectual disability
Exam-exhaustive fellowship reference on challenging behaviour in intellectual disability — Emerson definition and epidemiology, functional analysis (attention, escape, tangible, automatic), positive behaviour support multicomponent framework, medical and psychiatric differentials, NICE NG11, limited antipsychotic role (Tyrer 2008), deprescribing and STOMP principles, capacity and restrictive practices. FRANZCP-primary, globally tagged.
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Red flags
- New or sudden change in behaviour — treat as medical until proven otherwise (pain, constipation, dental disease, infection, epilepsy, delirium, medication toxicity or akathisia)
- Severe self-injury or aggression causing tissue damage, fracture risk, or placement crisis — safety plan and functional analysis urgently; do not start open-ended antipsychotics without formulation
- Long-term antipsychotic for 'behaviour' with no recorded mental illness — deprescribe carefully with multiagency support (STOMP principles)
- Diagnostic overshadowing: depression, psychosis, trauma or abuse attributed solely to intellectual disability
- High-dose polypharmacy or chemical restraint without capacity discussion, monitoring, or review date
- Restrictive practices used without least-restrictive alternatives, documentation, or behaviour support plan
Meet the patient
A 34-year-old man with severe intellectual disability and no speech has been head-banging for two weeks. The group home staff are exhausted; one has a bruised forearm from trying to restrain him. They fax a referral asking you to "increase the risperidone."[2][11]
He is already on risperidone 3 mg daily, prescribed three years ago "for behaviour," with no recorded mental illness and no review date. Two questions decide whether he gets better or gets another milligram. What is the behaviour achieving for him? And what changed two weeks ago?[1][6]
References15ShowHide
- [1]Deb S, Kwok H, Bertelli M, et al.; Guideline Development Group of the WPA Section on Psychiatry of Intellectual Disability International guide to prescribing psychotropic medication for the management of problem behaviours in adults with intellectual disabilities World Psychiatry, 2009.PMID 19812757
- [2]Emerson E, Kiernan C, Alborz A, et al. The prevalence of challenging behaviors: a total population study Res Dev Disabil, 2001.PMID 11263632
- [3]Tyrer P, Oliver-Africano PC, Ahmed Z, et al. Risperidone, haloperidol, and placebo in the treatment of aggressive challenging behaviour in patients with intellectual disability: a randomised controlled trial Lancet, 2008.PMID 18177776
- [4]Sheehan R, Hassiotis A, Walters K, et al. Mental illness, challenging behaviour, and psychotropic drug prescribing in people with intellectual disability: UK population based cohort study BMJ, 2015.PMID 26330451
- [5]Sheehan R, Hassiotis A Reduction or discontinuation of antipsychotics for challenging behaviour in adults with intellectual disability: a systematic review Lancet Psychiatry, 2017.PMID 27838214
- [6]Iwata BA, Dorsey MF, Slifer KJ, Bauman KE, Richman GS Toward a functional analysis of self-injury J Appl Behav Anal, 1994.PMID 8063622
- [7]Aman MG, De Smedt G, Derivan A, Lyons B, Findling RL; Risperidone Disruptive Behavior Study Group Double-blind, placebo-controlled study of risperidone for the treatment of disruptive behaviors in children with subaverage intelligence Am J Psychiatry, 2002.PMID 12153826
- [8]McCracken JT, McGough J, Shah B, et al.; Research Units on Pediatric Psychopharmacology Autism Network Risperidone in children with autism and serious behavioral problems N Engl J Med, 2002.PMID 12151468
- [9]Hassiotis A, Poppe M, Strydom A, et al. Clinical outcomes of staff training in positive behaviour support to reduce challenging behaviour in adults with intellectual disability: cluster randomised controlled trial Lancet Psychiatry, 2018.PMID 29436314
- [10]Hassiotis A, Poppe M, Strydom A, et al. Positive behaviour support training for staff for treating challenging behaviour in people with intellectual disabilities: a cluster RCT Health Technol Assess, 2018.PMID 29596045
- [11]Trollor JN, Salomon C, Franklin C Prescribing psychotropic drugs to adults with an intellectual disability Aust Prescr, 2016.PMID 27756975
- [12]Willner P, Rose J, Jahoda A, et al. Group-based cognitive-behavioural anger management for people with mild to moderate intellectual disabilities: cluster randomised controlled trial Br J Psychiatry, 2013.PMID 23520220
- [13]de Kuijper GM, Hoekstra PJ Physicians' reasons not to discontinue long-term used off-label antipsychotic drugs in people with intellectual disability J Intellect Disabil Res, 2017.PMID 28560761
- [14]Snyder R, Turgay A, Aman M, Binder C, Fisman S, Carroll A; Risperidone Conduct Study Group Effects of risperidone on conduct and disruptive behavior disorders in children with subaverage IQs J Am Acad Child Adolesc Psychiatry, 2002.PMID 12218423
- [15]Beqiraj L, Denne LD, Hastings RP, Paris A Positive behavioural support for children and young people with developmental disabilities in special education settings: A systematic review J Appl Res Intellect Disabil, 2022.PMID 35199433