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

Challenging Behaviour

& Mental Health: Prevention,

Early Intervention & Ongoing Support

Eric EmersonInstitute 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

1

2

3

4

5

6

1 2 3 4 5

Equivalised Income Quintile

OR

Conduct DisorderEmotional DisorderID

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 distributed3. 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 distributed3. People do not ‘grow out’ of these

problems4. 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 sustain10.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 StatusSEP

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 StatusSEP

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

PreventionEarly identification and interventionOngoing 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

Copy of the slides …..

eric.emerson@lancaster.ac.uk