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Physical Aggression towards Others in Adults with Learning Disabilities: Prevalence and Associated Factors

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Title: Physical Aggression towards Others in Adults with Learning Disabilities: Prevalence and Associated Factors
Language: English
Authors: Tyrer, F., McGrother, C. W., Thorp, C. F., Donaldson, M., Bhaumik, S., Watson, J. M., Hollin, C.
Source: Journal of Intellectual Disability Research. Apr 2006 50(4):295-304.
Availability: Blackwell Publishing. 350 Main Street, Malden, MA 02148. Tel: 800-835-6770; Tel: 781-388-8599; Fax: 781-388-8232; e-mail: customerservices@blackwellpublishing.com; Web site: http://www.blackwellpublishing.com/jnl_default.asp.
Peer Reviewed: Y
Page Count: 10
Publication Date: 2006
Document Type: Journal Articles
Reports - Research
Descriptors: Incidence, Aggression, Learning Disabilities, Adults, Case Studies, Multiple Regression Analysis, Behavior Problems, Foreign Countries, Coping, Caregivers, Symptoms (Individual Disorders)
Geographic Terms: United Kingdom (England)
DOI: 10.1111/j.1365-2788.2005.00774.x
ISSN: 0964-2633
Abstract: Background: Many people with learning disabilities (LD) show aggressive behaviour, but the extent of the problem and its associated factors and effects are unclear. Methods: A cross-sectional analysis was carried out using interview data from 3065 adults with LD on the Leicestershire LD Register. Physical aggression towards others was defined as carers reporting frequent (more than three times per week) and/or severe episodes. Individuals with and without aggression were compared using multiple logistic regression models for potential physical and psychological factors. Results: Carers reported that 443 (14%) of adults were physically aggressive towards others. Men (P=0.001), younger individuals (P is less than 0.001), people with more severe LD (P is less than 0.001) and those in institutional settings (P is less than 0.001) had a significantly higher prevalence of physical aggression. People with Down syndrome had a lower prevalence of physical aggression (P is less than 0.001). After adjustment, we found no relationship between aggression and the presence of epilepsy or autism. Among psychological factors, symptoms of frustration (P is less than 0.001) and mood swings (P is less than 0.001) were associated with higher levels of aggression. Failure to cope among carers was reported by 14% overall: 42% of people caring for adults with aggression said they were unable to cope compared with 10% of those caring for adults without aggression. Conclusions: Physical aggression towards other people presents a significant challenge to carers of adults with LD. Further research is needed to identify aetiological factors with a view to finding effective interventions to reduce, and improve management of, this behaviour.
Abstractor: Author
Number of References: 38
Entry Date: 2006
Accession Number: EJ732949
Database: ERIC
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  Value: <anid>AN0019892659;eul01apr.06;2019Jun04.10:25;v2.2.500</anid> <title id="AN0019892659-1">Physical aggression towards others in adults with learning disabilities: prevalence and associated factors. </title> <p>Background  Many people with learning disabilities (LD) show aggressive behaviour, but the extent of the problem and its associated factors and effects are unclear. Methods  A cross‐sectional analysis was carried out using interview data from 3065 adults with LD on the Leicestershire LD Register. Physical aggression towards others was defined as carers reporting frequent (more than three times per week) and/or severe episodes. Individuals with and without aggression were compared using multiple logistic regression models for potential physical and psychological factors. Results  Carers reported that 443 (14%) of adults were physically aggressive towards others. Men (P = 0.001), younger individuals (P < 0.001), people with more severe LD (P < 0.001) and those in institutional settings (P < 0.001) had a significantly higher prevalence of physical aggression. People with Down syndrome had a lower prevalence of physical aggression (P < 0.001). After adjustment, we found no relationship between aggression and the presence of epilepsy or autism. Among psychological factors, symptoms of frustration (P < 0.001) and mood swings (P < 0.001) were associated with higher levels of aggression. Failure to cope among carers was reported by 14% overall: 42% of people caring for adults with aggression said they were unable to cope compared with 10% of those caring for adults without aggression. Conclusions  Physical aggression towards other people presents a significant challenge to carers of adults with LD. Further research is needed to identify aetiological factors with a view to finding effective interventions to reduce, and improve management of, this behaviour.</p> <p>Keywords: behaviour; cross‐sectional study; cohort; Leicestershire; aggression</p> <p>Aggression is a recognized problem for both formal and informal carers of people with learning disabilities (LD) ([<reflink idref="bib14" id="ref1">14</reflink>]; [<reflink idref="bib6" id="ref2">6</reflink>]), and is one of many manifestations of the more widely researched challenging behaviour ([<reflink idref="bib10" id="ref3">10</reflink>]). Individuals with LD often have communication difficulties and are unable to self‐report any aggressive behaviour. Therefore identification is often dependent on caregivers' perceptions of the problem, which is influenced by their own ability to cope. The level of reporting may also depend on the specific setting. For example, behaviour that is acceptable in a hospital or residential home may not be acceptable in the family environment.</p> <p>There is no single widely accepted definition of aggression. The term 'aggression' may refer to a whole range of behaviours from throwing objects around the room to actual bodily harm to other people. A recent meta‐analysis by [<reflink idref="bib21" id="ref4">21</reflink>]) pooled studies on challenging behaviour in adults and children with LD and included 10 studies of aggression. The pooled studies defined aggression in different ways, from attacking or being physically aggressive to other people ([<reflink idref="bib33" id="ref5">33</reflink>]; [<reflink idref="bib1" id="ref6">1</reflink>]; [<reflink idref="bib18" id="ref7">18</reflink>]; [<reflink idref="bib2" id="ref8">2</reflink>]) to 'hitting out or attacking others' ([<reflink idref="bib4" id="ref9">4</reflink>]); 'aggression' ([<reflink idref="bib30" id="ref10">30</reflink>]; [<reflink idref="bib13" id="ref11">13</reflink>]), 'aggressive behaviour disorder' ([<reflink idref="bib25" id="ref12">25</reflink>]); 'threatens or does physical violence' ([<reflink idref="bib11" id="ref13">11</reflink>]) and 'explosive or assaultive behaviour towards property or other individuals' ([<reflink idref="bib6" id="ref14">6</reflink>]). It is therefore difficult to make comparisons between studies and to assess the extent of the problem in individuals with LD.</p> <p>In this study, we have focused on physical aggression towards other people because this can be considered to be the most severe form of aggressive behaviour. Although verbal aggression or destroying property can be extremely distressing for carers, physically hurting other people not only presents significant challenges for those providing clinical and day‐to‐day care but also impacts on the physical safety of carers and the general public. There have been few population studies looking specifically at physically aggressive behaviour towards others. Those that have been carried out give prevalence estimates of 11% for 'physical assault upon others' ([<reflink idref="bib18" id="ref15">18</reflink>]) and 22% for 'physical aggression towards others' ([<reflink idref="bib2" id="ref16">2</reflink>]). [<reflink idref="bib14" id="ref17">14</reflink>]) found a low prevalence (0.7%) of aggressive behaviour that was thought to risk 'serious or very serious injury towards another person'. However, even less severe behaviour is detrimental to carers' quality of life and may also lead to a shift from home to institutional care ([<reflink idref="bib24" id="ref18">24</reflink>]).</p> <p>Previous research has found an increased risk of physical aggression towards others in people with more severe LD ([<reflink idref="bib26" id="ref19">26</reflink>]). In contrast, a relationship between severe LD and physical aggression has not always been found ([<reflink idref="bib8" id="ref20">8</reflink>]), and an opposite relationship was found by [<reflink idref="bib9" id="ref21">9</reflink>]) where general aggression (including 'verbal aggression' and 'meanness/cruelty') was more likely to be shown by individuals with greater expressive communication skills inferring milder levels of LD. Evidence also suggests that the prevalence of physical aggression is higher in residents of institutional settings compared with those living with their family or independently ([<reflink idref="bib18" id="ref22">18</reflink>]). Although early studies observed that people with seizures ([<reflink idref="bib12" id="ref23">12</reflink>]) were more likely to be physically aggressive, more recent research suggests that this is not the case ([<reflink idref="bib7" id="ref24">7</reflink>]). People with Down syndrome may also be less likely to be physically aggressive ([<reflink idref="bib5" id="ref25">5</reflink>]).</p> <p>There is now increasing evidence that mood, particularly depression, may influence aggressive behaviour. In people with more severe LD, it has been suggested that depression may present itself in terms of behaviour problems ([<reflink idref="bib35" id="ref26">35</reflink>]) or worsening of existing behaviour problems ([<reflink idref="bib20" id="ref27">20</reflink>]) and general aggressive behaviour ([<reflink idref="bib32" id="ref28">32</reflink>]), although this relationship is not always found ([<reflink idref="bib34" id="ref29">34</reflink>]). Certainly, further investigation of the relationship between mood and aggression is required because there is conflicting evidence in this area, and this information is valuable for the development of future interventions.</p> <p>The aims of this study were (<reflink idref="bib1" id="ref30">1</reflink>) to report on the prevalence of physical aggression towards other people in adults with LD living in Leicestershire; (<reflink idref="bib2" id="ref31">2</reflink>) to describe the associated demographic, physical and psychological factors of physical aggression; and (<reflink idref="bib3" id="ref32">3</reflink>) to assess the impact of physical aggression on carers.</p> <hd id="AN0019892659-2">Materials and methods</hd> <p></p> <hd id="AN0019892659-3">Study population</hd> <p>This cross‐sectional study was carried out using the Leicestershire LD Register. The register, which has been described in detail elsewhere ([<reflink idref="bib23" id="ref33">23</reflink>]), is an open cohort of adults over the age of 19 with LD living in the city of Leicester, Leicestershire and Rutland. Leicester, Leicestershire and Rutland have a combined population of around 700 000 adults in this age group ([<reflink idref="bib27" id="ref34">27</reflink>]) and the administrative prevalence of LD has been estimated to be approximately 4 per 1000 in this population ([<reflink idref="bib22" id="ref35">22</reflink>]). The register has local research ethics approval and was established in 1986 during a period of extensive and active case finding. The definition of a learning disability is based on a moderate, severe or profound developmental intellectual impairment ([<reflink idref="bib38" id="ref36">38</reflink>]) with adaptive behaviour problems and the use of and/or probable need for some form of specialist service because of intellectual impairment ([<reflink idref="bib15" id="ref37">15</reflink>]). A 95% ascertainment rate is estimated. Where possible, all carers (the main informal carer at home or professional carer in residential care) or clients (if they are living independently) are interviewed every 5–7 years by specially trained interviewers solely employed for this purpose. Response rate for home interviews is 95%. Information is collected about demographic details, skill level, sensory impairments, continence, behaviour, psychological symptoms, use of and need for services, and the health of informal carers.</p> <p>Information from the most recent interview was collected for all individuals on the register with an interview between 1 January 1993 and 31 December 2004. The questionnaire incorporates the validated Disability Assessment Schedule (DAS) and provides data about the presence, frequency and severity of behaviour problems ([<reflink idref="bib16" id="ref38">16</reflink>]). One of the questions asked the carer whether the individual had been 'physically aggressive towards others' within the last 12 months. This question was used as our outcome measure. For the purpose of this study, aggression was defined as being present if the carer answered 'yes' to this question and either reported that it was severe and occurred frequently (more than three times per week); or was severe in nature but occurred less frequently; or was considered to be less severe but occurred frequently (more than three times per week). Aggression was defined as being absent if the carer reported that it had never occurred; if the individual had exhibited this behaviour in the past but it was controlled in the current environment; or if the behaviour occurred but it was considered by the carer to be a lesser management problem. Carers were also asked whether the individual's behaviour problems had resulted in severe physical hurt to others requiring medical or nursing attention; less severe physical hurt to others; exclusion from day care; police taking or threatening to take formal action; or whether the carers themselves felt unable to cope with the behaviour.</p> <hd id="AN0019892659-4">Demographic and co‐morbid factors</hd> <p>The age of the individual with LD at interview was categorized into 10‐year age bands (<20; 20–29; 30–39; 40–49; 50–59; 60–69; 70 or over). Ethnicity was grouped into white (British, Irish or other European); South Asian (Indian, Pakistani or Bangladeshi); other/not known. Similarly, residence was categorized by level of independence: living independently (alone, with spouse or with friends); living with relatives; non‐NHS residential; NHS residential; other/not known.</p> <p>Questions within the DAS on an individual's skill level are similar to those in the Vineland scale ([<reflink idref="bib36" id="ref39">36</reflink>]). From this, a developmental quotient (DQ), which provides a good estimate of intelligence quotient (IQ) in this population, was calculated for each individual based on the developmental age. The calculation used equations derived from comparison between DAS and Vineland in a subgroup analysis ([<reflink idref="bib2" id="ref40">2</reflink>]) and involved five variables of function (writing, domestic skills, understanding money, understanding time, orientation) and an additional dependency variable for the degree of daytime supervision needed. Level of LD was categorized using estimated IQ: profound (<20); severe (20–34); moderate (35–49) and mild (50–69).</p> <p>As well as carers being asked at interview whether the individual has Down syndrome, the register has independent information from doctors about the diagnosis in 96% of cases. Epilepsy was defined as being present if the carer reported that the individual suffered from epilepsy, or was experiencing seizures (once per month), or was taking medication to prevent seizures. The register records autistic traits, of which people on the LD register have a maximum of five: little or no speech; a lack of social interaction; a lack of empathy; the presence of constant stereotypies; and the presence of elaborate routines or obsessional behaviour. A person was defined as having autism if they had four or five autistic traits ([<reflink idref="bib2" id="ref41">2</reflink>]).</p> <hd id="AN0019892659-5">Psychological symptoms</hd> <p>Psychological symptoms were incorporated into the questionnaire before any validated instruments had been developed and were based on the clinical experience of psychiatrists at the time. Carers were asked whether any of the following symptoms had been present recently: 'frustration'; 'unhappiness/upset/crying'; 'withdrawal'; 'anxiousness/phobias/irrational fears'; 'mood swings/intermittent confusion'; 'feeling things always set against them'; 'lethargy'. On responding 'yes' to any or all of these questions, the carers were then asked to assess whether they considered these symptoms to be major or minor.</p> <p>As part of the register's system for identifying people with LD, notification details are received from all people with LD seen by Leicestershire LD psychiatric services. This process has been carried out since 1987; almost 50% of people on the Leicestershire LD Register have been seen at some point by psychiatric services.</p> <hd id="AN0019892659-6">Analyses</hd> <p>Analyses were carried out in Stata 8 ([<reflink idref="bib37" id="ref42">37</reflink>]). The population was described in terms of each potential associated factor. Demographic and co‐morbid characteristics of individuals with and without aggression were then compared and analysed univariately. To identify independent risk factors, we then adjusted for factors that were significant at the 5% level in the univariate analysis using a logistic regression model. A separate logistic regression model was used to explore the relationship between psychological symptoms and physical aggression adjusting for age, gender and estimated IQ.</p> <hd id="AN0019892659-7">Results</hd> <p></p> <hd id="AN0019892659-8">Population characteristics</hd> <p>There were 3062 individuals on the Leicestershire LD Register with interview data between 1 January 1993 and 31 December 2004. There were slightly more men (57%) than women (43%), and most individuals (73%) were under the age of 50 at the time of their interview (Table 1). Around 84% of individuals were living with relatives (<emph>n</emph> = 1349) or in residential care (<emph>n</emph> = 1217); the remaining 16% were living independently (<emph>n</emph> = 235), in NHS accommodation (<emph>n</emph> = 245), or had a missing (<emph>n</emph> = 9) or 'other' (<emph>n</emph> = 7) accommodation status. There were 1715 (56%) individuals in total who were known to Leicestershire LD psychiatric services.</p> <p>1 Characteristics of study population</p> <p> <ephtml> <table><thead valign="bottom"><tr><th>Characteristic (range)</th><th>Categories</th><th>No. individuals(% of total)</th><th>No. with aggression(% of category)</th></tr></thead><tbody valign="top"><tr><td>Total</td><td /><td>3062 (100)</td><td>443 (14)</td></tr><tr><td>Gender</td><td>Male</td><td>1735 (57)</td><td>287 (17)</td></tr><tr><td>Female</td><td>1327 (43)</td><td>156 (12)</td></tr><tr><td>Age (19–92)</td><td><20</td><td> 237 (8)</td><td> 56 (24)</td></tr><tr><td>20–29</td><td> 657 (21)</td><td>108 (16)</td></tr><tr><td>30–39</td><td> 719 (23)</td><td>124 (17)</td></tr><tr><td>40–49</td><td> 629 (21)</td><td> 84 (13)</td></tr><tr><td>50–59</td><td> 417 (14)</td><td> 39 (9)</td></tr><tr><td>60–69</td><td> 259 (8)</td><td> 23 (9)</td></tr><tr><td>≥70</td><td> 144 (5)</td><td>  9 (6)</td></tr><tr><td>Ethnicity</td><td>White</td><td>2633 (86)</td><td>372 (14)</td></tr><tr><td>South Asian</td><td> 340 (11)</td><td> 57 (17)</td></tr><tr><td>Other/unknown</td><td>  89 (3)</td><td> 14 (16)</td></tr><tr><td>Residential status</td><td>Independent</td><td> 235 (8)</td><td> 14 (6)</td></tr><tr><td>With relatives</td><td>1349 (44)</td><td>157 (12)</td></tr><tr><td>Residential home</td><td>1217 (40)</td><td>202 (17)</td></tr><tr><td>NHS accommodation</td><td> 245 (8)</td><td> 68 (28)</td></tr><tr><td>Other/unknown</td><td>  16 (1)</td><td>  2 (13)</td></tr><tr><td>Estimated IQ (8–69)</td><td>Mild (50–69)</td><td> 710 (23)</td><td> 59 (8)</td></tr><tr><td>Moderate (35–49)</td><td> 607 (20)</td><td> 68 (11)</td></tr><tr><td>Severe (20–34)</td><td> 799 (26)</td><td>133 (17)</td></tr><tr><td>Profound (<20)</td><td> 848 (28)</td><td>166 (20)</td></tr><tr><td>Unknown</td><td>  98 (3)</td><td> 17 (17)</td></tr><tr><td>Epilepsy</td><td>Present</td><td> 812 (27)</td><td>152 (19)</td></tr><tr><td>Absent</td><td>2250 (73)</td><td>291 (13)</td></tr><tr><td>Down syndrome</td><td>Present</td><td> 502 (16)</td><td> 30 (6)</td></tr><tr><td>Absent</td><td>2560 (84)</td><td>413 (16)</td></tr><tr><td>Autism</td><td>Present</td><td>  68 (2)</td><td> 20 (29)</td></tr><tr><td>Absent</td><td>2994 (98)</td><td>423 (14)</td></tr><tr><td>Known to psychiatric services</td><td>Yes</td><td>1715 (56)</td><td>329 (19)</td></tr><tr><td>No</td><td>1347 (44)</td><td>114 (8)</td></tr><tr><td>Physical hurt to others</td><td>Severe</td><td> 105 (3)</td><td> 80 (76)</td></tr><tr><td>Less severe</td><td> 532 (17)</td><td>311 (58)</td></tr><tr><td>None</td><td>2425 (79)</td><td> 52 (2)</td></tr><tr><td>Exclusion from day care</td><td>Permanent</td><td>  36 (1)</td><td> 17 (47)</td></tr><tr><td>Temporary</td><td> 153 (5)</td><td> 73 (48)</td></tr><tr><td>None</td><td>2873 (94)</td><td>353 (12)</td></tr><tr><td>Police taking or threatening to take formal action</td><td>Yes</td><td>  95 (3)</td><td> 45 (47)</td></tr><tr><td>No</td><td>2967 (97)</td><td>398 (13)</td></tr><tr><td>Carers felt unable to cope</td><td>Yes</td><td> 424 (14)</td><td>186 (44)</td></tr><tr><td>No</td><td>2638 (86)</td><td>257 (10)</td></tr></tbody></table> </ephtml> </p> <p>1 IQ, intelligence quotient; NHS, National Health Service.</p> <hd id="AN0019892659-9">Prevalence</hd> <p></p> <hd id="AN0019892659-10">Study population</hd> <p>In the study population, 443 (14%) individuals had a record of being physically aggressive towards others; 97 (3%) individuals exhibited behaviour described as severe and occurring frequently (more than three times per week); 74 (2%) exhibited behaviour described as less severe but occurring frequently; and 272 (9%) exhibited behaviour described as severe but occurring less often (three times per week or less).</p> <hd id="AN0019892659-11">Subgroup with aggression</hd> <p>In the subgroup of 443 individuals exhibiting aggression towards others, the behaviour of 80 (18%) individuals was reported as having resulted in serious injury to others within the last two years; and the behaviour of another 311 (70%) in lesser injury. Only 52 (12%) individuals' behaviour was said to have resulted in no injuries. Further examination of the carers of the 80 individuals reporting serious injury showed that 31% had reported severe and frequent episodes of aggression compared with 14% reporting severe and less frequent episodes and 15% reporting less severe but frequent episodes.</p> <p>Within the subgroup with aggressive behaviour, the behaviour of 17 (4%) individuals had led to their being excluded permanently from day care and that of 45 (10%) individuals had resulted in the police taking or threatening to take formal action. Further, 186 (42%) carers of adults with aggression said that they felt unable to cope with the behaviour.</p> <p>The majority of individuals with aggression (<emph>n</emph> = 329; 74%) were known to LD psychiatric services. Of those not known to services (<emph>n</emph> = 114), more than half (<emph>n</emph> = 62; 54%) were living with relatives and 35 (58%) carers in this latter group said that they felt unable to cope with the behaviour.</p> <hd id="AN0019892659-12">Associated factors</hd> <p></p> <hd id="AN0019892659-13">Demographic and co‐morbid factors</hd> <p>Table 2 shows the relationship between physical aggression and the demographic and co‐morbid factors analysed. All the factors apart from ethnicity were univariately associated with physical aggression. In the multivariate model, aggression was found to be more common in men (OR = 1.44, 95% CI = 1.16–1.79) and in younger individuals, with a gradient effect ranging from 1.00 for the youngest to 0.08 for the oldest. Compared with those living independently, aggression was almost five times as likely in residents of NHS accommodation (OR = 4.90; 95% CI = 2.52–9.52) and almost three times as likely in people living in residential care (OR = 2.79; 95% CI = 1.55–5.02).</p> <p>2 Demographic and co‐morbid factors associated with physical aggression towards others in adults with learning disabilities (LD)</p> <p> <ephtml> <table><thead valign="bottom"><tr><th>Characteristic</th><th /><th>Univariate</th><th>Multivariate*</th></tr><tr><th>OR</th><th>95% CI</th><th><italic>P</italic>‐value</th><th>OR</th><th>95% CI</th><th><italic>P</italic>‐value</th></tr></thead><tbody valign="top"><tr><td>Gender</td><td>Male</td><td>1.49</td><td>1.21–1.83</td><td><0.001</td><td>1.44</td><td>1.16–1.79</td><td>0.001</td></tr><tr><td>Age</td><td><20</td><td>1.00</td><td>–</td><td><0.001</td><td>1.00</td><td>–</td><td><0.001</td></tr><tr><td>20–29</td><td>0.64</td><td>0.44–0.91</td><td /><td>0.61</td><td>0.42–0.90</td><td /></tr><tr><td>30–39</td><td>0.67</td><td>0.47–0.96</td><td /><td>0.47</td><td>0.32–0.70</td><td /></tr><tr><td>40–49</td><td>0.50</td><td>0.34–0.73</td><td /><td>0.32</td><td>0.21–0.48</td><td /></tr><tr><td>50–59</td><td>0.33</td><td>0.21–0.52</td><td /><td>0.18</td><td>0.11–0.29</td><td /></tr><tr><td>60–69</td><td>0.31</td><td>0.19–0.53</td><td /><td>0.14</td><td>0.08–0.24</td><td /></tr><tr><td>≥70</td><td>0.22</td><td>0.10–0.45</td><td /><td>0.08</td><td>0.04–0.17</td><td /></tr><tr><td>Ethnicity</td><td>White</td><td>1.00</td><td>–</td><td> 0.42</td><td>–</td><td>–</td><td /></tr><tr><td>Asian</td><td>1.22</td><td>0.90–1.66</td><td /><td /><td /><td /></tr><tr><td>Other/unknown</td><td>1.13</td><td>0.62–2.03</td><td /><td /><td /><td /></tr><tr><td>Residential status</td><td>Independent</td><td>1.00</td><td>–</td><td><0.001</td><td>1.00</td><td>–</td><td><0.001</td></tr><tr><td>Living with relatives</td><td>2.08</td><td>1.18–3.66</td><td /><td>1.11</td><td>0.61–2.01</td><td /></tr><tr><td>Residential home</td><td>3.14</td><td>1.79–5.50</td><td /><td>2.79</td><td>1.55–5.02</td><td /></tr><tr><td>NHS accommodation</td><td>6.06</td><td>3.30–11.14</td><td /><td>4.90</td><td>2.52–9.52</td><td /></tr><tr><td>Other/unknown</td><td>2.26</td><td>0.47–10.92</td><td /><td>1.22</td><td>0.24–6.08</td><td /></tr><tr><td>Estimated IQ</td><td>Mild: 50–69</td><td>1.00</td><td>–</td><td><0.001</td><td>1.00</td><td>–</td><td><0.001</td></tr><tr><td>Moderate: 35–49</td><td>1.39</td><td>0.96–2.01</td><td /><td>1.62</td><td>1.11–2.38</td><td /></tr><tr><td>Severe: 20–34</td><td>2.20</td><td>1.59–3.05</td><td /><td>2.62</td><td>1.85–3.71</td><td /></tr><tr><td>Profound: <20</td><td>2.69</td><td>1.96–3.68</td><td /><td>2.58</td><td>1.81–3.70</td><td /></tr><tr><td>Unknown</td><td>2.32</td><td>1.29–4.16</td><td /><td>2.10</td><td>1.12–3.94</td><td /></tr><tr><td>Epilepsy</td><td>Present</td><td>1.55</td><td>1.25–1.92</td><td><0.001</td><td>0.95</td><td>0.74–1.21</td><td>0.67</td></tr><tr><td>Down syndrome</td><td>Present</td><td>0.33</td><td>0.23–0.48</td><td><0.001</td><td>0.32</td><td>0.22–0.48</td><td><0.001</td></tr><tr><td>Autism</td><td>Present</td><td>2.53</td><td>1.49–4.31</td><td> 0.001</td><td>1.32</td><td>0.74–2.35</td><td>0.34</td></tr></tbody></table> </ephtml> </p> <ulist> <item>2 * Adjusted for all other demographic and co‐morbid factors displayed in the table.</item> <item>3 OR, odds ratio; CI, confidence interval. IQ, intelligence quotient; NHS, National Health Service.</item> </ulist> <p>Aggression was also more common in individuals with more severe LD, with a gradient effect ranging from 1.00 for those with mild LD to 2.58 for those with profound LD.</p> <p>We found that people with Down syndrome were more than three times less likely to have reported aggression (OR = 0.32; 95% CI = 0.22–0.48). However, although the presence of epilepsy and presence of autistic traits were univariately associated with higher rates of aggression, neither was significant after adjustment for other factors.</p> <hd id="AN0019892659-14">Psychological symptoms</hd> <p>All the psychological symptoms were univariately associated with physical aggression, with an increased risk of aggression as the symptoms became more severe (Table 3). The multivariate model revealed that only people exhibiting frustration (<emph>P</emph> < 0.001) or mood swings (<emph>P</emph> < 0.001) were more likely to be aggressive (after adjusting for all other psychological symptoms, age, gender and estimated IQ).</p> <p>3 Psychological symptoms associated with physical aggression towards others in adults with learning disabilities (LD)*</p> <p> <ephtml> <table><thead valign="bottom"><tr><th>Psychologicalsymptom</th><th /><th>No. withaggression (%)</th><th>Univariate</th><th>Multivariate†</th></tr><tr><th>OR</th><th>95% CI</th><th><italic>P</italic>‐value</th><th>OR</th><th>95% CI</th><th><italic>P</italic>‐value</th></tr></thead><tbody valign="top"><tr><td>Frustration</td><td>None</td><td> 79 (6)</td><td> 1.00</td><td>–</td><td><0.001</td><td>1.00</td><td>–</td><td><0.001</td></tr><tr><td>Minor</td><td> 99 (11)</td><td> 1.98</td><td> 1.45–2.69</td><td> 1.27</td><td>0.90–1.79</td><td /><td /></tr><tr><td>Major</td><td>188 (38)</td><td> 9.82</td><td> 7.34–13.12</td><td> 3.09</td><td>2.15–4.44</td><td /><td /></tr><tr><td>Unhappiness, upset, crying</td><td>None</td><td>158 (9)</td><td> 1.00</td><td>–</td><td><0.001</td><td>1.00</td><td>–</td><td>0.24</td></tr><tr><td>Minor</td><td>113 (16)</td><td> 1.94</td><td> 1.50–2.52</td><td> 1.17</td><td>0.85–1.60</td><td /><td /></tr><tr><td>Major</td><td> 95 (37)</td><td> 6.13</td><td> 4.54–8.29</td><td> 1.43</td><td>0.94–2.19</td><td /><td /></tr><tr><td>Withdrawal</td><td>None</td><td>197 (10)</td><td> 1.00</td><td>–</td><td><0.001</td><td>1.00</td><td>–</td><td>0.68</td></tr><tr><td>Minor</td><td>108 (20)</td><td> 2.37</td><td> 1.83–3.06</td><td> 1.12</td><td>0.82–1.54</td><td /><td /></tr><tr><td>Major</td><td> 61 (34)</td><td> 4.87</td><td> 3.46–6.85</td><td> 0.94</td><td>0.60–1.50</td><td /><td /></tr><tr><td>Anxiousness, phobias, irrational fears</td><td>None</td><td>169 (10)</td><td> 1.00</td><td>–</td><td><0.001</td><td>1.00</td><td>–</td><td>0.52</td></tr><tr><td>Minor</td><td> 85 (13)</td><td> 1.37</td><td> 1.04–1.81</td><td> 1.00</td><td>0.72–1.38</td><td /><td /></tr><tr><td>Major</td><td>112 (28)</td><td> 3.61</td><td> 2.75–4.72</td><td> 1.21</td><td>0.85–1.72</td><td /><td /></tr><tr><td>Mood swings, intermittent confusion</td><td>None</td><td> 81 (5)</td><td> 1.00</td><td>–</td><td><0.001</td><td>1.00</td><td>–</td><td><0.001</td></tr><tr><td>Minor</td><td> 76 (11)</td><td> 2.21</td><td> 1.60–3.07</td><td> 1.91</td><td>1.34–2.73</td><td /><td /></tr><tr><td>Major</td><td>209 (45)</td><td>15.20</td><td>11.39–20.28</td><td> 9.28</td><td>6.43–13.40</td><td /><td /></tr><tr><td>Feeling things always set against them</td><td>None</td><td>242 (11)</td><td> 1.00</td><td>–</td><td><0.001</td><td>1.00</td><td>–</td><td>0.92</td></tr><tr><td>Minor</td><td> 65 (18)</td><td> 1.79</td><td> 1.33–2.42</td><td> 0.99</td><td>0.67–1.46</td><td /><td /></tr><tr><td>Major</td><td> 59 (32)</td><td> 3.83</td><td> 2.74–5.36</td><td> 0.91</td><td>0.56–1.46</td><td /><td /></tr><tr><td>Lethargy</td><td>None</td><td>222 (11)</td><td> 1.00</td><td>–</td><td><0.001</td><td>1.00</td><td>–</td><td>0.76</td></tr><tr><td>Minor</td><td> 86 (16)</td><td> 1.58</td><td> 1.21–2.07</td><td> 0.88</td><td>0.64–1.23</td><td /><td /></tr><tr><td>Major</td><td> 58 (27)</td><td> 3.01</td><td> 2.16–4.19</td><td> 0.96</td><td>0.63–1.48</td><td /><td /></tr></tbody></table> </ephtml> </p> <ulist> <item>4 * Individuals with missing data for any of the symptoms (<emph>n</emph> = 265) were excluded from the analyses.</item> <item>5 † Adjusted for age, gender, estimated IQ (intelligence quotient) and all other psychological symptoms displayed.</item> <item>6 OR, odds ratio; CI, confidence interval.</item> </ulist> <hd id="AN0019892659-15">Discussion</hd> <p>We found that the prevalence of physical aggression towards others in adults with LD living in the city of Leicester, Leicestershire and Rutland was 14%. This is consistent with [<reflink idref="bib18" id="ref43">18</reflink>]) New York study for 'physical assault upon others' given differences in study populations. A previous study using the Leicestershire LD Register found a higher prevalence of 22% for physical aggression towards others ([<reflink idref="bib2" id="ref44">2</reflink>]). However, this study used a lower threshold than the current study for the definition of physical aggression and included individuals whose behaviour was considered to be a 'lesser management problem'.</p> <p>We also found that the behaviour of 3% of the population was reported to have caused serious injury to others requiring nursing or medical attention within the previous two years. This subgroup of 80 individuals, 25 of whom were residing in the community, present a very real challenge to carers and impact upon the safety and well‐being of family members, professionals and others.</p> <p>The higher prevalence of reported aggression found in men and in the younger age groups follows the pattern found in the general population, where aggression towards other people is more common in men and decreases with age ([<reflink idref="bib17" id="ref45">17</reflink>]; [<reflink idref="bib31" id="ref46">31</reflink>]). The increased risk of aggression in people with more severe LD is also consistent with other research ([<reflink idref="bib26" id="ref47">26</reflink>]), but not all ([<reflink idref="bib8" id="ref48">8</reflink>]). Aggression may be more prevalent in people with more severe LD if they lack the cognitive ability to understand the implications of hurting others. Another possibility is that carers of individuals with more severe LD may perceive their aggressive behaviour more negatively because they are generally more stressed and these carers may be more likely to report physical aggression.</p> <p>In our population, people living in NHS accommodation and residential care were more likely to have reported aggression compared with people living independently. It has previously been recognized that there is a selection mechanism whereby aggressive behaviour is a reason for people with LD to be admitted or re‐admitted to institutional settings ([<reflink idref="bib19" id="ref49">19</reflink>]). Carers of individuals with LD who exhibit aggressive behaviour may be more likely to seek other care options, which would explain the higher prevalence of this behaviour in institutional settings. Additionally, institutional settings themselves have been shown to provoke feelings of frustration, helplessness, injustice and anger ([<reflink idref="bib3" id="ref50">3</reflink>]), suggesting that the environment itself may also influence individuals' behaviour.</p> <p>Our findings that people with Down syndrome were around three times less likely to be physically aggressive is consistent with previous research ([<reflink idref="bib5" id="ref51">5</reflink>]). It is possible that carers of people with Down syndrome rate behaviour problems of the same degree of severity as being less of a problem than carers of those without Down syndrome. This may weaken the negative relationship we have found between Down syndrome and physical aggression, although it is unlikely to explain this fully. Our finding that the presence of epilepsy and autism were not independently associated with aggression suggests that they may be influenced by other factors such as level of intellectual disability, which is in keeping with other research in this area.</p> <p>We found a higher prevalence of physical aggression in people who were reported as having severe mood swings and/or major frustration. Previous research has found a relationship between violence and anger in people with LD ([<reflink idref="bib29" id="ref52">29</reflink>]) and also in the general population ([<reflink idref="bib28" id="ref53">28</reflink>]). If frustration and mood swings are associated with anger, this may explain our findings. Similarly, frustration and mood swings may also be indicators of psychiatric illness, such as anxiety or depression. However, this is a complex area and needs to be investigated further with validated instruments before any inferences can be made.</p> <p>In terms of the burden on carers, individuals' behaviour had resulted in permanent exclusion from day care in 1% of cases. Overall, 14% of carers felt that they were unable to cope with the behaviour problems: 42% of people caring for adults with aggression said they were unable to cope compared with 10% of those caring for adults without aggression. Further, more than a quarter of individuals whose carers reported physical aggression were not known to LD psychiatric services in the area.</p> <p>This study has the advantage of being a large population‐based study, containing a representative group of people with moderate to profound LD who are in contact with services and who represent the administrative prevalence of LD as a whole. We recognize that people with aggression are more likely to be referred to psychiatric services and, by implication, to be notified to the Leicestershire LD Register, which may inflate the prevalence of aggression in our population.</p> <p>One limitation of this study is that in collecting a wide range of variables retrospectively there may be a problem with recall. In particular, asking carers to report retrospectively on the frequency of aggressive behaviour and events occurring as a result of this behaviour may lead to recall bias. However, in a subset analysis in which the definition of aggression towards others was restricted to behaviour reported to occur more than three times per week (<emph>n</emph> = 171), the effect of gender (<emph>P</emph> = 0.02), age (<emph>P</emph> < 0.001), residential status (<emph>P</emph> < 0.001), estimated IQ (<emph>P</emph> < 0.001) and Down syndrome (<emph>P</emph> = 0.002) remained. Thus, there does not appear to be a significant influence of recall bias on our main findings.</p> <p>Physical aggression towards others is an important issue in terms of the distress it causes and carers' safety. This study has demonstrated that physical aggression occurs in a substantial number of adults with LD. We have found that aggressive behaviour is more prevalent in men, in younger individuals, in people living in institutional settings, in people with more severe LD and in those exhibiting frustration and/or mood swings. We have also found that aggressive behaviour is less prevalent in people with Down syndrome. Further research is now needed to confirm these findings, in particular to investigate more fully the relationship between physical aggression, frustration and mood swings in people with LD. Identifying aetological factors with a view to finding cognitive or treatment interventions to reduce, and improve management of, this behaviour is also important. More research is also needed on the potential for improving support for carers of people with both LD and physical aggression.</p> <hd id="AN0019892659-16">Acknowledgements</hd> <p>The authors gratefully acknowledge the contribution of the Leicestershire Learning Disabilities Team in collecting the data. This work was funded by the Leicestershire Partnership NHS Trust and the Department of Health.</p> <ref id="AN0019892659-17"> <title> References </title> <blist> <bibl id="bib1" idref="ref6" type="bt">1</bibl> <bibtext> Ando H. & Yoshimura I. (1979) Comprehension skill levels and prevalence of maladaptive behaviors in autistic and mentally retarded children. A statistical study. Child Psychiatry and Human Development 9, 131 – 6.</bibtext> </blist> <blist> <bibl id="bib2" idref="ref8" type="bt">2</bibl> <bibtext> Bhaumik S., Branford D., McGrother C. & Thorp C. (1997) Autistic traits in adults with learning disabilities. 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Items – Name: Title
  Label: Title
  Group: Ti
  Data: Physical Aggression towards Others in Adults with Learning Disabilities: Prevalence and Associated Factors
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Tyrer%2C+F%2E%22">Tyrer, F.</searchLink><br /><searchLink fieldCode="AR" term="%22McGrother%2C+C%2E+W%2E%22">McGrother, C. W.</searchLink><br /><searchLink fieldCode="AR" term="%22Thorp%2C+C%2E+F%2E%22">Thorp, C. F.</searchLink><br /><searchLink fieldCode="AR" term="%22Donaldson%2C+M%2E%22">Donaldson, M.</searchLink><br /><searchLink fieldCode="AR" term="%22Bhaumik%2C+S%2E%22">Bhaumik, S.</searchLink><br /><searchLink fieldCode="AR" term="%22Watson%2C+J%2E+M%2E%22">Watson, J. M.</searchLink><br /><searchLink fieldCode="AR" term="%22Hollin%2C+C%2E%22">Hollin, C.</searchLink>
– Name: TitleSource
  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Journal+of+Intellectual+Disability+Research%22"><i>Journal of Intellectual Disability Research</i></searchLink>. Apr 2006 50(4):295-304.
– Name: Avail
  Label: Availability
  Group: Avail
  Data: Blackwell Publishing. 350 Main Street, Malden, MA 02148. Tel: 800-835-6770; Tel: 781-388-8599; Fax: 781-388-8232; e-mail: customerservices@blackwellpublishing.com; Web site: http://www.blackwellpublishing.com/jnl_default.asp.
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 10
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2006
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Incidence%22">Incidence</searchLink><br /><searchLink fieldCode="DE" term="%22Aggression%22">Aggression</searchLink><br /><searchLink fieldCode="DE" term="%22Learning+Disabilities%22">Learning Disabilities</searchLink><br /><searchLink fieldCode="DE" term="%22Adults%22">Adults</searchLink><br /><searchLink fieldCode="DE" term="%22Case+Studies%22">Case Studies</searchLink><br /><searchLink fieldCode="DE" term="%22Multiple+Regression+Analysis%22">Multiple Regression Analysis</searchLink><br /><searchLink fieldCode="DE" term="%22Behavior+Problems%22">Behavior Problems</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink><br /><searchLink fieldCode="DE" term="%22Coping%22">Coping</searchLink><br /><searchLink fieldCode="DE" term="%22Caregivers%22">Caregivers</searchLink><br /><searchLink fieldCode="DE" term="%22Symptoms+%28Individual+Disorders%29%22">Symptoms (Individual Disorders)</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22United+Kingdom+%28England%29%22">United Kingdom (England)</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1111/j.1365-2788.2005.00774.x
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0964-2633
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Background: Many people with learning disabilities (LD) show aggressive behaviour, but the extent of the problem and its associated factors and effects are unclear. Methods: A cross-sectional analysis was carried out using interview data from 3065 adults with LD on the Leicestershire LD Register. Physical aggression towards others was defined as carers reporting frequent (more than three times per week) and/or severe episodes. Individuals with and without aggression were compared using multiple logistic regression models for potential physical and psychological factors. Results: Carers reported that 443 (14%) of adults were physically aggressive towards others. Men (P=0.001), younger individuals (P is less than 0.001), people with more severe LD (P is less than 0.001) and those in institutional settings (P is less than 0.001) had a significantly higher prevalence of physical aggression. People with Down syndrome had a lower prevalence of physical aggression (P is less than 0.001). After adjustment, we found no relationship between aggression and the presence of epilepsy or autism. Among psychological factors, symptoms of frustration (P is less than 0.001) and mood swings (P is less than 0.001) were associated with higher levels of aggression. Failure to cope among carers was reported by 14% overall: 42% of people caring for adults with aggression said they were unable to cope compared with 10% of those caring for adults without aggression. Conclusions: Physical aggression towards other people presents a significant challenge to carers of adults with LD. Further research is needed to identify aetiological factors with a view to finding effective interventions to reduce, and improve management of, this behaviour.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: Author
– Name: Ref
  Label: Number of References
  Group: RefInfo
  Data: 38
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2006
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ732949
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ732949
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      – Type: doi
        Value: 10.1111/j.1365-2788.2005.00774.x
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      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 10
        StartPage: 295
    Subjects:
      – SubjectFull: Incidence
        Type: general
      – SubjectFull: Aggression
        Type: general
      – SubjectFull: Learning Disabilities
        Type: general
      – SubjectFull: Adults
        Type: general
      – SubjectFull: Case Studies
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      – SubjectFull: Coping
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      – SubjectFull: Caregivers
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      – SubjectFull: Symptoms (Individual Disorders)
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      – SubjectFull: United Kingdom (England)
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    Titles:
      – TitleFull: Physical Aggression towards Others in Adults with Learning Disabilities: Prevalence and Associated Factors
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