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. 2023 Feb 6;2(2):CD003406.
doi: 10.1002/14651858.CD003406.pub5.

Behavioural and cognitive-behavioural interventions for outwardly directed aggressive behaviour in people with intellectual disabilities

David Prior  1 , Soe Win  2 , Angela Hassiotis  3 , Ian Hall  4 , Michele A Martiello  5 , Afia K Ali  6
Affiliations

Behavioural and cognitive-behavioural interventions for outwardly directed aggressive behaviour in people with intellectual disabilities

David Prior et al. Cochrane Database Syst Rev. .

Abstract

Background: Outwardly directed aggressive behaviour in people with intellectual disabilities is a significant issue that may lead to poor quality of life, social exclusion and inpatient psychiatric admissions. Cognitive and behavioural approaches have been developed to manage aggressive behaviour but the effectiveness of these interventions on reducing aggressive behaviour and other outcomes are unclear. This is the third update of this review and adds nine new studies, resulting in a total of 15 studies in this review.

Objectives: To evaluate the efficacy of behavioural and cognitive-behavioural interventions on outwardly directed aggressive behaviour compared to usual care, wait-list controls or no treatment in people with intellectual disability. We also evaluated enhanced interventions compared to non-enhanced interventions.

Search methods: We used standard, extensive Cochrane search methods. The latest search date was March 2022. We revised the search terms to include positive behaviour support (PBS).

Selection criteria: We included randomised and quasi-randomised trials of children and adults with intellectual disability of any duration, setting and any eligible comparator.

Data collection and analysis: We used standard Cochrane methods. Our primary outcomes were change in 1. aggressive behaviour, 2. ability to control anger, and 3. adaptive functioning, and 4.

Adverse effects: Our secondary outcomes were change in 5. mental state, 6. medication, 7. care needs and 8. quality of life, and 9. frequency of service utilisation and 10. user satisfaction data. We used GRADE to assess certainty of evidence for each outcome. We expressed treatment effects as mean differences (MD) or odds ratios (OR), with 95% confidence intervals (CI). Where possible, we pooled data using a fixed-effect model.

Main results: This updated version comprises nine new studies giving 15 included studies and 921 participants. The update also adds new interventions including parent training (two studies), mindfulness-based positive behaviour support (MBPBS) (two studies), reciprocal imitation training (RIT; one study) and dialectical behavioural therapy (DBT; one study). It also adds two new studies on PBS. Most studies were based in the community (14 studies), and one was in an inpatient forensic service. Eleven studies involved adults only. The remaining studies involved children (one study), children and adolescents (one study), adolescents (one study), and adolescents and adults (one study). One study included boys with fragile X syndrome. Six studies were conducted in the UK, seven in the USA, one in Canada and one in Germany. Only five studies described sources of funding. Four studies compared anger management based on cognitive behaviour therapy to a wait-list or no treatment control group (n = 263); two studies compared PBS with treatment as usual (TAU) (n = 308); two studies compared carer training on mindfulness and PBS with PBS only (n = 128); two studies involving parent training on behavioural approaches compared to wait-list control or TAU (n = 99); one study of mindfulness to a wait-list control (n = 34); one study of adapted dialectal behavioural therapy compared to wait-list control (n = 21); one study of RIT compared to an active control (n = 20) and one study of modified relaxation compared to an active control group (n = 12). There was moderate-certainty evidence that anger management may improve severity of aggressive behaviour post-treatment (MD -3.50, 95% CI -6.21 to -0.79; P = 0.01; 1 study, 158 participants); very low-certainty evidence that it might improve self-reported ability to control anger (MD -8.38, 95% CI -14.05 to -2.71; P = 0.004, I2 = 2%; 3 studies, 212 participants), adaptive functioning (MD -21.73, 95% CI -36.44 to -7.02; P = 0.004; 1 study, 28 participants) and psychiatric symptoms (MD -0.48, 95% CI -0.79 to -0.17; P = 0.002; 1 study, 28 participants) post-treatment; and very low-certainty evidence that it does not improve quality of life post-treatment (MD -5.60, 95% CI -18.11 to 6.91; P = 0.38; 1 study, 129 participants) or reduce service utilisation and costs at 10 months (MD 102.99 British pounds, 95% CI -117.16 to 323.14; P = 0.36; 1 study, 133 participants). There was moderate-certainty evidence that PBS may reduce aggressive behaviour post-treatment (MD -7.78, 95% CI -15.23 to -0.32; P = 0.04, I2 = 0%; 2 studies, 275 participants) and low-certainty evidence that it probably does not reduce aggressive behaviour at 12 months (MD -5.20, 95% CI -13.27 to 2.87; P = 0.21; 1 study, 225 participants). There was low-certainty evidence that PBS does not improve mental state post-treatment (OR 1.44, 95% CI 0.83 to 2.49; P = 1.21; 1 study, 214 participants) and very low-certainty evidence that it might not reduce service utilisation at 12 months (MD -448.00 British pounds, 95% CI -1660.83 to 764.83; P = 0.47; 1 study, 225 participants). There was very low-certainty evidence that mindfulness may reduce incidents of physical aggression (MD -2.80, 95% CI -4.37 to -1.23; P < 0.001; 1 study; 34 participants) and low-certainty evidence that MBPBS may reduce incidents of aggression post-treatment (MD -10.27, 95% CI -14.86 to -5.67; P < 0.001, I2 = 87%; 2 studies, 128 participants). Reasons for downgrading the certainty of evidence were risk of bias (particularly selection and performance bias); imprecision (results from single, often small studies, wide CIs, and CIs crossing the null effect); and inconsistency (statistical heterogeneity).

Authors' conclusions: There is moderate-certainty evidence that cognitive-behavioural approaches such as anger management and PBS may reduce outwardly directed aggressive behaviour in the short term but there is less certainty about the evidence in the medium and long term, particularly in relation to other outcomes such as quality of life. There is some evidence to suggest that combining more than one intervention may have cumulative benefits. Most studies were small and there is a need for larger, robust randomised controlled trials, particularly for interventions where the certainty of evidence is very low. More trials are needed that focus on children and whether psychological interventions lead to reductions in the use of psychotropic medications.

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Conflict of interest statement

DP is a 'Psychiatry of Intellectual Disabilities' Higher Trainee with the North London Higher Training Scheme, National Health Service (NHS). He has declared that he has no conflicts of interests.

SW is a Consultant Psychiatrist in Intellectual Disability Psychiatry. He has declared that he has no conflicts of interest.

AH is a Consultant Psychiatrist with the Camden Learning Disability Service and Professor of Psychiatry of Intellectual Disabilities at University College London (UCL), Division of Psychiatry. She reports receiving grants from the National Institute for Health Research (NIHR), Health Technology Assessment (HTA; funders of the Hassiotis 2018 study). AH occasionally receives honoraria and personal payments from academic institutions as an invited speaker/workshop leader and author of commissioned articles. AH is the author of two studies included in this review: Hassiotis 2009, funded by the South Essex Partnership University Foundation NHS Trust, and Hassiotis 2018, funded by NIHR HTA; payments were made to UCL (AH has not received any direct funds for her research). The funder of these studies had no role in the design, data collection, data analysis, data interpretation and reporting. Additionally, AH was not directly involved in assessing the eligibility of these studies, extracting data, assessing the risk of bias or grading the certainty of the evidence. However, she had an overview of the work completed for this document. She declares that at no point has she attempted to influence her co‐authors' decisions about these papers.

IH is a Consultant Psychiatrist for people with intellectual disability with the East London NHS Foundation Trust. He reports occasional payments for lectures on services for people with intellectual disability, and travel expenses to attend a conference to disseminate findings of a study, both from University College London (UCL); both personal payments. IH has peer reviewed research papers in academic journals relating to studies at UCL. IH reports that he is an investigator on the Hassiotis 2018 study, which is included in this review; the study was funded by NIHR, with payments for IH's involvement made to the East London NHS foundation Trust; however, the funder had no role in the study design, data collection, data analysis, data interpretation and reporting. Additionally, IH was not involved in making decisions about the inclusion of the paper in the review (i.e. he was not involved in assessing the eligibility of study, extracting data, assessing the risk of bias or grading the certainty of the evidence).

MM is a 'Psychiatry of Intellectual Disabilities' Higher Trainee with the North London Higher Training Scheme, National Health Service (NHS). He has declared that he has no conflicts of interests.

AA is a Consultant Psychiatrist for people with intellectual disability working at the East London NHS Foundation Trust and honorary Senior Clinical Lecturer at Queen Mary's University of London.

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
1.1
1.1. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 1: Aggressive behaviour: severity of incidents: Aberrant Behaviour Checklist (ABC) – Hyperactivity subscale – key worker report
1.2
1.2. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 2: Aggressive behaviour: severity of incidents: ABC – Irritability subscale – key worker report
1.3
1.3. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 3: Aggressive behaviour: severity of incidents: ABC – Hyperactivity subscale – home carer report
1.4
1.4. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 4: Aggressive behaviour: severity of incidents: ABC – Irritability subscale – home carer report
1.5
1.5. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 5: Aggressive behaviour: severity of incidents: Modified Overt Aggression Scale (MOAS) – key worker report
1.6
1.6. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 6: Aggressive behaviour: severity of incidents: MOAS – home carer report
1.7
1.7. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 7: Aggressive behaviour: severity of incidents: Aggression Questionnaire – Physical Aggression subscale (problem‐solving intervention vs control)
1.8
1.8. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 8: Aggressive behaviour: severity of incidents: Aggression Questionnaire – Verbal Aggression subscale (problem‐solving intervention vs control)
1.9
1.9. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 9: Aggressive behaviour: severity of incidents: Aggression Questionnaire – Anger subscale (problem‐solving intervention vs control)
1.10
1.10. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 10: Aggressive behaviour: severity of incidents: Aggression Questionnaire – Hostility subscale (problem‐solving intervention vs control)
1.11
1.11. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 11: Aggressive behaviour: severity of incidents: Aggression Questionnaire – Indirect Aggression subscale (problem‐solving vs control)
1.12
1.12. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 12: Aggressive behaviour: severity of incidents: Aggression Questionnaire – Physical Aggression subscale (cognitive re‐appraisal intervention vs control)
1.13
1.13. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 13: Aggressive behaviour: severity of incidents: Aggression Questionnaire – Verbal Aggression subscale (cognitive re‐appraisal vs control)
1.14
1.14. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 14: Aggressive behaviour: severity of incidents: Aggression Questionnaire – Anger subscale (cognitive re‐appraisal vs control)
1.15
1.15. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 15: Aggressive behaviour: severity of incidents: Aggression Questionnaire – Hostility subscale (cognitive re‐appraisal vs control)
1.16
1.16. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 16: Aggressive behaviour: severity of incidents: Aggression Questionnaire – Indirect Aggression subscale (cognitive re‐appraisal vs control)
1.17
1.17. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 17: Ability to control anger: Provocation Inventory (PI) – self‐report
1.18
1.18. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 18: Ability to control anger: PI – Irritations subscale
1.19
1.19. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 19: Ability to control anger: PI – Disrespect subscale
1.20
1.20. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 20: Ability to control anger: PI – Unfairness subscale
1.21
1.21. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 21: Ability to control anger: PI – Annoying Traits subscale
1.22
1.22. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 22: Ability to control anger: PI – Frustrations subscale
1.23
1.23. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 23: Ability to control anger: PI – key worker and carer reports
1.24
1.24. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 24: Ability to control anger: Profile of Anger Coping Skills (PACS) – self‐report
1.25
1.25. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 25: Ability to control anger: PACS – key worker and carer reports
1.26
1.26. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 26: Adaptive functioning: Adaptive Behaviour Scale – Revised, Part II (ABS‐II)
1.27
1.27. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 27: Mental state: psychiatric symptoms measured using the Brief Symptom Inventory (BSI)
1.28
1.28. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 28: Mental state: psychological distress measured using the Subjective Units of Distress Scale (SUDS)
1.29
1.29. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 29: Mental state: depression: Glasgow Depression Scale – Intellectual Disability (GDS‐ID)
1.30
1.30. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 30: Mental state: anxiety: Glasgow Anxiety Scale – Intellectual Disability (GAS‐ID)
1.31
1.31. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 31: Self‐esteem: Rosenberg Self‐Esteem Scale (SES)
1.32
1.32. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 32: Quality of life: Comprehensive Quality of Life Scale: Intellectual Disability (COMQoL‐ID)
1.33
1.33. Analysis
Comparison 1: Anger management vs wait‐list control, Outcome 33: Costs of service utilisation: Client Service Receipt Inventory (CSRI): cost per person per week of health and social care resource (in British pounds)
2.1
2.1. Analysis
Comparison 2: Positive behavioural support (PBS) or behavioural support team vs treatment as usual (TAU), Outcome 1: Aggressive behaviour: Aberrant Behaviour Checklist (ABC) Total
2.2
2.2. Analysis
Comparison 2: Positive behavioural support (PBS) or behavioural support team vs treatment as usual (TAU), Outcome 2: Mental state: Common Mental Disorder (CMD) assessed using the Mini‐Psychiatric Assessment Schedule for Adults with Developmental Disabilities (Mini PAS‐ADD)
2.3
2.3. Analysis
Comparison 2: Positive behavioural support (PBS) or behavioural support team vs treatment as usual (TAU), Outcome 3: Mental state: severe mental illness (SMI) assessed using the Mini PAS‐ADD
2.4
2.4. Analysis
Comparison 2: Positive behavioural support (PBS) or behavioural support team vs treatment as usual (TAU), Outcome 4: Mental state: prevalence of affective disorders assessed using the PAS‐ADD checklist
2.5
2.5. Analysis
Comparison 2: Positive behavioural support (PBS) or behavioural support team vs treatment as usual (TAU), Outcome 5: Mental state: prevalence of psychotic disorders assessed by the PAS‐ADD checklist
2.6
2.6. Analysis
Comparison 2: Positive behavioural support (PBS) or behavioural support team vs treatment as usual (TAU), Outcome 6: Mental state: prevalence of organic mental disorder assessed by the PAS‐ADD Checklist
2.7
2.7. Analysis
Comparison 2: Positive behavioural support (PBS) or behavioural support team vs treatment as usual (TAU), Outcome 7: Costs of service utilisation: Client Service receipt Inventory (CSRI) – Total mean health and social care costs per participant
3.1
3.1. Analysis
Comparison 3: Meditation based on mindfulness vs wait‐list control, Outcome 1: Aggressive behaviour: frequency of incidents: number of incidents of physical aggression per week during treatment (12 weeks)
3.2
3.2. Analysis
Comparison 3: Meditation based on mindfulness vs wait‐list control, Outcome 2: Aggressive behaviour: frequency of incidents: number of incidents of verbal aggression per week during treatment (12 weeks)
4.1
4.1. Analysis
Comparison 4: Carer training in mindfulness‐based positive behaviour support (MBPBS) vs positive behaviour support (PBS), Outcome 1: Aggressive behaviour: aggressive events – carer reports
4.2
4.2. Analysis
Comparison 4: Carer training in mindfulness‐based positive behaviour support (MBPBS) vs positive behaviour support (PBS), Outcome 2: Aggressive behaviour: staff injuries – carer reports
4.3
4.3. Analysis
Comparison 4: Carer training in mindfulness‐based positive behaviour support (MBPBS) vs positive behaviour support (PBS), Outcome 3: Aggressive behaviour: peer injuries – carer reports
4.4
4.4. Analysis
Comparison 4: Carer training in mindfulness‐based positive behaviour support (MBPBS) vs positive behaviour support (PBS), Outcome 4: Reduction in (additional) medication: emergency medication – carer reports
4.5
4.5. Analysis
Comparison 4: Carer training in mindfulness‐based positive behaviour support (MBPBS) vs positive behaviour support (PBS), Outcome 5: Reduction in care needs: physical restraints – carer reports
4.6
4.6. Analysis
Comparison 4: Carer training in mindfulness‐based positive behaviour support (MBPBS) vs positive behaviour support (PBS), Outcome 6: Reduction in care needs: 1:1 staffing – carer reports
5.1
5.1. Analysis
Comparison 5: Adapted dialectical behaviour therapy (aDBT) vs no treatment control, Outcome 1: Ability to control anger: Novaco Anger Scale: Provocation Inventory (NAS:PI) – client ratings
5.2
5.2. Analysis
Comparison 5: Adapted dialectical behaviour therapy (aDBT) vs no treatment control, Outcome 2: Ability to control anger: NAS:PI – carer ratings
5.3
5.3. Analysis
Comparison 5: Adapted dialectical behaviour therapy (aDBT) vs no treatment control, Outcome 3: Mental state: Reiss Screen for Maladaptive Behaviour (REISS) – client ratings
5.4
5.4. Analysis
Comparison 5: Adapted dialectical behaviour therapy (aDBT) vs no treatment control, Outcome 4: Mental state: REISS – carer ratings
6.1
6.1. Analysis
Comparison 6: Reciprocal imitation training (RIT) vs 1:1 instruction on individualised treatment plan, Outcome 1: Aggressive behaviour: Aberrant Behaviour Checklist (ABC) – Residential
6.2
6.2. Analysis
Comparison 6: Reciprocal imitation training (RIT) vs 1:1 instruction on individualised treatment plan, Outcome 2: Adaptive functioning: Matson Evaluation of Social Skills for Individuals with Severe Mental Retardation (MESSIER)
6.3
6.3. Analysis
Comparison 6: Reciprocal imitation training (RIT) vs 1:1 instruction on individualised treatment plan, Outcome 3: Adaptive functioning: Unstructured Imitation Assessment (UIA)
6.4
6.4. Analysis
Comparison 6: Reciprocal imitation training (RIT) vs 1:1 instruction on individualised treatment plan, Outcome 4: Adaptive functioning: Motor Imitation Scale (MIS)
7.1
7.1. Analysis
Comparison 7: Parent training in behavioural approaches vs treatment as usual (TAU) or wait‐list control, Outcome 1: Proportion of participants who achieved a positive response on the ABC (≥ 25% reduction in scores)
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Update of

Comment in

References

References to studies included in this review

Collado‐Castillo 2010 {published data only}
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References to studies excluded from this review

Bagaiolo 2017 {published data only}
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    1. Hassiotis AA, Hall I. Behavioural and cognitive-behavioural interventions for outwardly-directed aggressive behaviour in people with learning disabilities. Cochrane Database of Systematic Reviews 2001, Issue 4. Art. No: CD003406. [DOI: 10.1002/14651858.CD003406] - DOI - PubMed
Hassiotis 2004
    1. Hassiotis AA, Hall I. Behavioural and cognitive-behavioural interventions for outwardly-directed aggressive behaviour in people with learning disabilities. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No: CD003406. [DOI: 10.1002/14651858.CD003406.pub2] [PMID: ] - DOI - PubMed
Hassiotis 2008
    1. Hassiotis AA, Hall I. Behavioural and cognitive-behavioural interventions for outwardly-directed aggressive behaviour in people with learning disabilities. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No: CD003406. [DOI: 10.1002/14651858.CD003406.pub3] [PMID: ] - DOI - PubMed

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