Aggressive challenging behavior in people with intellectual disability is a frequent reason for referral to secondary care services and is associated with direct harm, social exclusion, and criminal sanctions. Understanding the factors underlying aggressive challenging behavior and predictors of adverse clinical outcome is important in providing services and developing effective interventions.

This was a retrospective total-population cohort study using electronic records linked with Hospital Episode Statistics data. Participants were adults with intellectual disability accessing secondary services at a large mental healthcare provider in London, United Kingdom, between 2014 and 2018. An adverse outcome was defined as at least one of the following: admission to a mental health hospital, Mental Health Act assessment, contact with a psychiatric crisis team or attendance at an emergency department.

There were 1,515 patient episodes related to 1,225 individuals, of which 1,019 episodes were reported as displaying aggressive challenging behavior. Increased episode length, being younger, psychotropic medication use, pervasive developmental disorder (PDD), more mentions of mood instability, agitation, and irritability, more contact with mental health professionals, and more mentions of social and/or home care package in-episode were all associated with increased odds of medium-high levels of aggression. Risk factors for an adverse clinical outcome in those who exhibited aggression included increased episode length, personality disorder, common mental disorder (CMD), more mentions of agitation in-episode, and contact with mental health professionals. PDD predicted better outcome.

Routinely collected data confirm aggressive challenging behavior as a common concern in adults with intellectual disability who are referred for specialist support and highlight factors likely to signal an adverse outcome. Treatment targets may include optimizing management of CMDs and agitation.

Behaviour that challenges in people with intellectual disability is associated with higher healthcare, social care and societal costs. Although behavioural therapies are widely used, there is limited evidence regarding the cost and quality-adjusted life-years (QALYs).

We aimed to assess the incremental cost per QALY gained of therapist training in positive behaviour support (PBS) and treatment as usual (TAU) compared with TAU using data from a cluster randomised controlled trial (Clinical Trials.gov registration: NCT01680276).

We conducted a cost-utility analysis (cost per QALY gained) of 23 teams randomised to PBS or TAU, with a total of 246 participants followed up over 36 months. The primary analysis was from a healthcare cost perspective with a secondary analysis from a societal cost perspective.

Over 36 months the intervention resulted in an additional 0.175 QALYs (discounted and adjusted 95% CI −0.068 to 0.418). The total cost of training in and delivery of PBS is £1598 per participant plus an additional cost of healthcare of £399 (discounted and adjusted 95% CI −603 to 1724). From a healthcare cost perspective there is an 85% probability that the intervention is cost-effective compared with TAU at a £30 000 willingness to pay for a QALY threshold.

There was a high probability that training in PBS is cost-effective as the cost of training and delivery of PBS is balanced out by modest improvements in quality of life. However, staff training in PBS is not supported given we found no evidence for clinical effectiveness.

Copy number variants (CNVs) are established risk factors for neurodevelopmental disorders. To date the study of CNVs in psychiatric illness has focused on single disorder populations. The role of CNVs in individuals with intellectual disabilities and psychiatric comorbidities are less well characterised.

To determine the type and frequency of CNVs in adults with intellectual disabilities and comorbid psychiatric disorders.

A chromosomal microarray analysis of 599 adults recruited from intellectual disabilities psychiatry services at three European sites.

The yield of pathogenic CNVs was high – 13%. Focusing on established neurodevelopmental disorder risk loci we find a significantly higher frequency in individuals with intellectual disabilities and comorbid psychiatric disorder (10%) compared with healthy controls (1.2%, P<0.0001), schizophrenia (3.1%, P<0.0001) and intellectual disability/autism spectrum disorder (6.5%, P < 0.00084) populations.

In the largest sample of adults with intellectual disabilities and comorbid psychiatric disorders to date, we find a high rate of pathogenic CNVs. This has clinical implications for the use of genetic investigations in intellectual disability psychiatry.

None.

There is little evidence to guide pharmacological treatment in adults with Down syndrome and Alzheimer's disease.

To investigate the effect of cholinesterase inhibitors or memantine on survival and function in adults with Down syndrome and Alzheimer's disease.

This was a naturalistic longitudinal follow-up of a clinical cohort of 310 people with Down syndrome diagnosed with Alzheimer's disease collected from specialist community services in England.

Median survival time (5.59 years, 95% CI 4.67–6.67) for those on medication (n = 145, mainly cholinesterase inhibitors) was significantly greater than for those not prescribed medication (n = 165) (3.45 years, 95% CI 2.91–4.13, log-rank test P<0.001). Sequential assessments demonstrated an early effect in maintaining cognitive function.

Cholinesterase inhibitors appear to offer benefit for people with Down syndrome and Alzheimer's disease that is comparable with sporadic Alzheimer's disease; a trial to test the effect of earlier treatment (prodromal Alzheimer's disease) in Down syndrome may be indicated.

A.S. has undertaken consulting for Ono Pharmaceuticals, outside the submitted work. Z.W. has received a consultancy fee and grant from GE Healthcare, outside the submitted work.

Staff training in positive behaviour support (PBS) is a widespread treatment approach for challenging behaviour in adults with intellectual disability.

To evaluate whether such training is clinically effective in reducing challenging behaviour during routine care (trial registration: NCT01680276).

We carried out a multicentre, cluster randomised controlled trial involving 23 community intellectual disability services in England, randomly allocated to manual-assisted staff training in PBS (n = 11) or treatment as usual (TAU, n = 12). Data were collected from 246 adult participants.

No treatment effects were found for the primary outcome (challenging behaviour over 12 months, adjusted mean difference = −2.14, 95% CI: −8.79, 4.51) or secondary outcomes.

Staff training in PBS, as applied in this study, did not reduce challenging behaviour. Further research should tackle implementation issues and endeavour to identify other interventions that can reduce challenging behaviour.

None.

To develop a programme to help undergraduate medical students and postgraduate trainees to improve their skills in communicating with people with intellectual disabilities through teaching sessions that had input from simulated patients with intellectual disabilities. We conducted four sessions of training for 47 undergraduate 4th-year medical students. The training involved a multiprofessional taught session followed by a clinical scenario role-play with simulated patients who were people with intellectual disabilities. The training was assessed by completing the healthcare provider questionnaire before and after the training.

There were improvements in the students' perceived skill, comfort and the type of clinical approach across all three scenarios.

By involving people with intellectual disabilities in training medical students there has been a significant improvement in students' communication skills in areas of perceived skills, comfort and type of clinical approach which will raise the quality of care provided by them in the future.

To analyse clinical outcome indicator data from the Health of the Nation Outcome Scales for People with Learning Disabilities (HoNOS-LD) in adults with intellectual disability admitted to mental health wards during a 19-month period; and to identify clinically relevant domains of change associated with in-patient admission.

Significant improvements were found in mental state, behaviour and social functioning. Improvements were also found in cognition and activities of daily living.

The HoNOS-LD is a useful tool for measuring clinical outcomes in several relevant domains and guiding in-patient treatment in learning disability psychiatry. It may also provide a currency for payment-by-results and influence the commissioning of learning disability services.

The cost of caring for people with intellectual disability currently makes up a large proportion of healthcare spending in western Europe, and may rise in line with the increasing numbers of people with intellectual disability now living to old age.

To report service use and costs of older people with intellectual disability and explore the influence of sociodemographic and illness-related determinants.

We collected data on receipt and costs of accommodation, health and personal care, physical as well as mental illness, dementia, sensory impairment and disability in a representative sample of adults with intellectual disability aged 60 years and older (n = 212).

The average weekly cost in GBP per older person was £790 (£41 080 per year). Accommodation accounted for 74%. Overall costs were highest for those living in congregate settings. Gender, intellectual disability severity, hearing impairment, physical disorder and mental illness had significant independent relationships with costs. Mental illness was associated with an additional weekly cost of £202.

Older adults with intellectual disability comprise about 0.15–0.25% of the population of England but consume up to 5% of the total personal care budget. Interventions that meet needs and might prove to be cost-effective should be sought.

There is a lack of validated instruments measuring perceived stigma in people with intellectual disability.

To develop a valid and reliable self-rated instrument to measure perceived stigma that can be completed by people with mild to moderate intellectual disability.

A literature search was used to generate a list of statements. Professionals, individuals with intellectual disability and carers were consulted about the suitability of statements. An instrument was developed containing statements about stigma with accompanying photographs. Test–retest reliability, internal consistency and the factor structure of the instrument were evaluated.

The instrument was completed by 109 people once and 88 people twice. Items with limited variability in responses and kappa coefficients lower than 0.4 were dropped. Exploratory factor analysis revealed two factors: ‘perceived discrimination’ (seven items) and ‘reaction to discrimination’ (four items). One item loaded onto both factors. Cronbach's alpha for the ten-item instrument was 0.84.

This instrument will further our understanding of the impact of stigma in people with intellectual disability in clinical and research settings.

To explore psychiatric trainees' (senior house officers') experience of a dedicated 6-month research post.

A questionnaire survey was conducted by post or e-mail of all previous post-holders of two research posts in a large London training rotation.

Twenty of the 28 post-holders completed the questionnaire. Overall, their experiences were positive in terms of research experience, exposure to academic environment and in facilitating future career opportunities. A minority of respondents found supervision to be unsatisfactory. Dedicated research posts are a valuable training opportunity that can complement clinical experience for trainees and foster an interest in research.

Increased risk of affective disorder in learning disability has been reported, although the extent to which this is due to adverse social and material circumstances is uncertain and there have been potential limitations in the measurement of affective disorder.

To determine risk of affective disorder in those classified with mild learning disability in the British 1946 birth cohort and to investigate whether this risk was accounted for by disadvantage in childhood and adulthood.

Learning disability was defined as the equivalent of an IQ ≤ 69 at age 15 years. The Present State Examination at age 36 years and the Psychiatric Symptom Frequency Scale at age 43 years provided psychiatric outcome measures.

Learning disability was associated with a fourfold increase in risk of affective disorder, not accounted for by social and material disadvantage or by medical disorder.

Learning disability is strongly associated with risk of affective disorder, persisting well into midlife.