A total population study of challenging behaviour in the county of Hedmark, Norway: Prevalence, and risk markers

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Abstract

Studies in Britain and the US indicate that 10–15% of people with mental retardation show challenging behaviour, like attacking others (aggression), self-injurious behaviour, destruction, and other difficult, disruptive or socially unacceptable acts. Most researchers indicate that challenging behaviour is more common among adolescents and young adults, among males, is associated with autism, and increases with lack of communication skills and severity of mental retardation. These factors can be understood as risk markers, and some of them can be decreased by preventive and treatment interventions, at least in principle. The present study confirmed most of the previous findings, with some exceptions: the prevalence of more demanding challenging behaviour was somewhat lower in the present study, and no association between gender and challenging behaviour was found. We also concluded that declining prevalence of challenging behaviour at older ages is not a result of a young age structure of the population.

Introduction

Some people with mental retardation show ‘challenging behaviour’, a term that applies exclusively to this population (Emerson, 2001). The most common forms are self-injury, attacking others (aggression), destruction, or other behaviours like unacceptable social and sexual conduct, screaming, non-compliance, and eating inedible objects. According to Emerson et al. (2001b), most studies of prevalence of challenging behaviour have been restricted in one of three ways: (1) some studies have focused on specific forms of challenging behaviour, like self-injury (Oliver, Murphy, & Corbett, 1987), or attacking others (Harris, 1993); (2) some studies have sampled subpopulations, such as people living in institutional settings or attending special schools; and (3) studies that have addressed multiple forms of challenging behaviour among all people with mental retardation have sometimes lacked detailed information about specific forms of challenging behaviour (e.g. Borthwick-Duffy, 1994, Jacobson, 1982, Rojahn, 1994). Consequently, at least some North American studies have reported large variations in prevalence rates (see Bruininks, Olson, Larson, & Lakin, 1994).

Increasingly, prevalence studies have employed a definition of challenging behaviour that distinguishes between more and less demanding challenging behaviour (Emerson et al., 2001b; Qureshi & Alborz, 1992). The former means that the person shows any challenging behaviour daily, that challenging behaviour usually prevents the person from taking part in programmes or activities, that more than one staff member is needed to physically control the behaviour, and that the behaviour causes major bodily injury to the person or others. The latter includes attacking others, self-injurious behaviour, destruction or otherwise problematic behaviour which do not meet these requirements.

Several studies have used this definition. A large-scale study in the North West of England found that 5.7% of the population administratively defined as having mental retardation manifested more severe challenging behaviour (Kiernan, Reeves, & Alborz, 1995; Kiernan & Qureshi, 1993; Qureshi & Alborz, 1992). In 1995, Emerson and Bromley found a prevalence of more demanding challenging behaviour of 7.8%. Quite logically, prevalence rates increase when studies also include less demanding challenging behaviour. A review of the literature conducted by Emerson et al. (2001b) indicated that more demanding challenging behaviour is manifested by 5–10% of the population, and by 10–15% when less demanding challenging behaviour is included. Most studies are conducted in Britain, and some in the US.

Researchers have investigated more than the overall prevalence of challenging behaviour. Emerson et al. (2001b) found that 7% of the population attacked others, 4–5% showed destruction, 4% showed self-injury, and about 10% showed other challenging behaviour. A majority showed two or more of these four general forms of challenging behaviour. People showing more demanding challenging behaviour have been demonstrated to show more general forms of challenging behaviour than people showing less demanding challenging behaviour (Emerson & Bromley, 1995).

Factors associated with challenging behaviour, that is, risk markers, have also been investigated. There is an increased prevalence of psychiatric symptomatology in people with challenging behaviour, compared with people without challenging behaviour (Holden & Gitlesen, 2003; Moss et al., 2000). Challenging behaviour is more common among people with autism (McClintock, Hall, & Oliver, 2003), and increases with greater needs for assistance and more restricted receptive and expressive communication, that is, increased severity of mental retardation (Emerson & Bromley, 1995; Emerson et al., 2001b). A majority of people with challenging behaviour, especially attacking others, are males, mostly adolescents or young adults (Emerson & Bromley, 1995; Emerson et al., 1997a, Emerson et al., 2001b; McClintock et al., 2003). Finally, about 50% of people with more demanding challenging behaviour have been living with their natural families (Emerson & Bromley, 1995; Emerson et al., 2001b).

Challenging behaviour may be problematic for staff or caregivers, and dangerous to the person and others. The behaviour may interfere with learning, development, and, depending on the social and cultural context, social participation. Severe self-injurious behaviour can be highly persistent (Emerson et al., 2001a), although data on the chronicity of self-injurious behaviour are somewhat lacking (McClintock et al., 2003). People with challenging behaviour comprise an overmedicated population (Matson et al., 2000). Challenging behaviour frequently causes stressful emotional reactions in caregivers (Hastings & Brown, 2002). The management and treatment of challenging behaviour often require highly specialized services (Emerson, 2001). The prevalence of challenging behaviour therefore has implications for the education of various professions and paraprofessions, as well as for training of staff and parents. The age of people with challenging behaviour, for example if a lot of youngsters show challenging behaviour, and whether they live with their natural families, has implications for planning of services. All in all, investigating the prevalence of challenging behaviour, and factors associated with it, have possible, practical consequences (Qureshi, 1994).

The present study was conducted in order to investigate the prevalence of all forms of challenging behaviour, and different factors associated with it, in a Norwegian population.

Section snippets

Participants

Participants (n = 904) were all people, both children and adults, with administratively defined mental retardation, that is, persons with mental retardation receiving at least a minimum of care from local health authorities, living in the county of Hedmark, Norway. Total population of the county is 188,000. This means an administrative prevalence of mental retardation of 0.48%. Each participant was allocated an informant, either a staff member or parent, judged to be in a good position to

Sample details

Age distribution of all participants was: 0–9 years, 6.1% (n = 50); 10–19 years, 13.2% (n = 109); 20–29 years, 11.5% (n = 95); 30–39 years, 17.2% (n = 142); 40–49 years, 16.1% (n = 133); 50–59 years, 20.6% (n = 170); 60–69 years, 9.7% (n = 80); 70–79 years, 3.9% (n = 32); 80–89 years, 1.7% (n = 14). 54.7% (n = 446) of the participants were males and 45.3% (n = 370) were females. 28.3% (n = 233) of the participants had mild; 45.1% (n = 371) had moderate; 15.6% (n = 128) had severe; and 10.9% (n = 90) had profound mental

Discussion

A main finding of this study was that 11.1% of people with administratively defined mental retardation showed challenging behaviour, mostly less demanding. Generally, people with more demanding challenging behaviour showed more forms of challenging behaviour than people with less demanding problems. Attacking others, and some specific forms of challenging behaviour were more common among people with more demanding challenging behaviour. Challenging behaviour was largely independent of gender,

Acknowledgement

We want to express our gratitude to Kristin Gjersem Trygstad for her extensive and patient assistance in the collection of data.

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