Challenging Behaviour & Mental Health: Prevention, Early Intervention & Ongoing Support Eric Emerson Institute for Health Research Lancaster University

The Plan … Summarise the evidence –10 things we know …. Implications –Prevention –Early intervention –Ongoing support

Ten Things We Know …. 1.Many people with intellectual disabilities have significant challenging behaviours or diagnosable mental health problems

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?

Ten Things We Know …. 1.Many people with intellectual disabilities have significant challenging behaviours or diagnosable mental health problems 2.Need is inequitably distributed

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

Household Income & Risk of Child Mental Health Problems in Britain

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

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)

Ten Things We Know …. 1.Many people with intellectual disabilities have significant challenging behaviours or diagnosable mental health problems 2.Need is inequitably distributed 3.People do not ‘grow out’ of these problems

Ten Things We Know …. 1.Many people with intellectual disabilities have significant challenging behaviours or diagnosable mental health problems 2.Need is inequitably distributed 3.People do not ‘grow out’ of these problems 4.There are very significant costs associated with these problems

Ten Things We Know … 5.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)

Ten Things We Know … 6.Some approaches to intervention can work –Positive behavioural approaches –Some drugs 7.Some do not –Semi-detached housing therapy –Some drugs

Ten Things We Know … 8.Intervening in adulthood is tough …. 9.… and difficult to sustain 10.Most people with significant levels of need do not get access to evidence-based support

Checklist Coverage? Equitable? Longer-term commitment? Range of expertise? Individualised? Contextualised? Evidence-based? Effectively monitored & managed?

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’

The Case for Prevention & Early Intervention Efficiency –Best use of resources Evidence –Generic (direct) –Specific (but indirect)

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

A Comprehensive Strategy Prevention Early intervention Ongoing support (technical, practical & emotional) –For people with intellectual disabilities –For carers

Social Determinants of Health Health Status SEP 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’)

Social Determinants of Health Health Status SEP 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)

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

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)

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

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

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

Pieces of the Jigsaw Prevention Early identification and intervention Ongoing support  Development & delivery of interventions  Practical & emotional support  Effective management

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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