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This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.

People with learning disabilities are more likely than others to display challenging behaviour that is aggressive. It can be verbal (shouting or swearing), non-verbal (such as hand gestures) or physical (hitting or kicking). A review analysed 59 relevant studies to identify the effective elements of interventions to reduce aggressive challenging behaviour.

The study found that successful interventions improve understanding of aggression, both among the people with learning disabilities themselves, and those providing care. These interventions promote a calm environment and address specific problems (such as a lack of social activities). Supportive relationships and trust between service users, therapists, carers and staff were essential. Staff needed protected time to develop their skills; managers’ buy-in and effective team working was helpful.  

The researchers have built these findings into a personalised approach called PETAL therapy (personalised treatment packages for adults with learning disabilities who display aggression in community settings). They are now testing the therapy in a randomised controlled trial.

These findings will be useful for anyone who spends time with people with learning disabilities, and those who manage or support teams of carers.

For information about managing challenging behaviour, visit the NHS website.

The issue: how to address aggression in people with learning disabilities

Some adults with learning disabilities (7 – 10%) show aggressive challenging behaviour weekly. It is most common in those with more severe learning disabilities. The behaviour can be triggered by a request (to take medication, for example), an event (when a person's needs are not being met by those around them) or their environment.

Aggressive challenging behaviour in people with learning disabilities can reduce their quality of life, put them at risk of injuries and cause social exclusion. It can also lead to admission to psychiatric care, even if the person does not have mental illness. This behaviour can result in restrictive practices, including being held still, put in a room alone, or given medicine to calm down.

Interventions are available to reduce aggressive challenging behaviour. However, little is known about how they work, and which elements of the interventions are effective. Researchers reviewed previous studies to fill this evidence gap.

What’s new?

The analysis included 59 studies of interventions for aggressive challenging behaviour in the community and in hospitals. Research in people with learning disabilities is limited. While more than half the studies (37) included adults with learning disabilities, others studied people with mental illness (10 studies), dementia (8), behavioural disorders (2) and autism spectrum disorder (2). The key findings were tested with 4 healthcare professionals, 1 family carer and 1 service manager.  

The study identified core components of successful interventions.

1. Service users’ skills and environment

Successful interventions addressed specific problems and provided tailored solutions for individuals. For example:

  • service providers and carers helped people understand and manage their challenging behaviour
  • a calm environment was created with calm colours and reduced echo
  • music and enjoyable social activities improved quality of life.

2. Supportive relationships

In successful interventions, communication between service users, families, carers and professionals was non-judgmental and built trust. For example:

  • therapists listened, and treated people with respect
  • carers learnt about triggers for challenging behaviour, how to respond with empathy, and how to look after themselves
  • staff were encouraged to see the person behind the anger, and to become confident in managing challenging behaviour.

3. Staff skills, time and team working

In successful interventions:

  • staff had protected time to learn how to personalise interventions and practice their skills
  • managers nominated champions to support and motivate staff to improve their knowledge
  • team members supported one another, and shared responsibilities and goals.

Why is this important?

People with learning disabilities often show aggressive challenging behaviour, which can impair their quality of life. The insights from this study could help reduce or manage this behaviour.

Successful interventions were personalised and tailored to suit the individual. Effective communication and trusting relationships between service users, carers, professionals and within staff teams helped deliver interventions. Buy-in from managers helped ensure that staff received training and that the environment was supportive.

What’s next?

This study is part of a larger project called PETAL (personalised treatment packages for adults with learning disabilities who display aggression in community settings). It informed the development of therapy which aims to support people to reduce aggressive behaviour.

The therapy has 7 elements: getting to know the person, understanding aggressive behaviour, communication, helping people manage their emotions, a calm environment, carer wellbeing and healthy habits.

The therapy was co-developed by people with learning disabilities and their families and carers, and is tailored to the individual. The team is now conducting a randomised controlled trial to compare PETAL therapy with usual care. Usual care might include behavioural support and input from psychiatrists or psychologists.

You may be interested to read

This Alert is based on: Royston R, and others. Complex interventions for aggressive challenging behaviour in adults with intellectual disability: A rapid realist review informed by multiple populations. PLOS One 2023; 18: e0285590.

A video explaining why the PETAL study is being done.

A webinar presenting the PETAL work.

Conflict of interest: No relevant conflicts were declared.

Funding: This study was funded by the NIHR Programme Grants for Applied Research.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Most NIHR Alerts are based on findings from a single study and may not reflect all research on a topic. The views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.

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