Journal of Intellectual & Developmental Disability, Vol. 25, No. 1, pp.

4157, 2000

Recent research on physical aggression in persons with intellectual disability: An overview

DAVID ALLEN1
Cardiff Community Healthcare NHS Trust/ Welsh Centre for Learning Disabilities
Physically aggressive behaviours pose major problems to carers supporting people with intellectual disability. This review considers the prevalence and nature of this form of challenging behaviour within this population and describes possible causal factors. The present status of both behavioural and pharmacological interventions for aggression are assessed, and the importance of devising reactive management plans for aggressive behaviours outlined. Implications for future practice are discussed.

INTRODUCTION Aggression is generally regarded as one of the most perplexing and stressful forms of challenging behaviour shown by people with intellectual disability (Burke, Burke, & Forehand, 1987; Dura, Mulick, & Myers, 1988; Tutton, Wynne-Willson, & Piachaud, 1990). It can act as a major barrier to community placement, it is frequently cited as a reason for placement break-down, and it increases the risk of failure in competitive employment (Gardener & Moffat, 1990). Aggression may also result in increased service costs as a result of high staff sickness and turnover rates, increased support & supervision costs, and potential compensatory payments to injured staff (Sigafoos, Elkins, Kerr, & Attwood, 1994). Not surprisingl y, aggression tends to be the most common form of challenging behaviour referred to specialist behavioural support teams and treatment units (Maguire & Piersel, 1992). The present paper will review recent research on the prevalence, causation, treatment and management of this form of challenging behaviour. References were initially derived from an automated literature search which was conducted using PsychLit and

Address for Correspondence: Dr David Allen, Consultant Clinical Psychologist & Honorary Lecturer, Cardiff Community Healthcare NHS Trust/ Welsh Centre for Learning Disabilities, Welsh Centre for Learning Disabilities, Meridian Court, North Rd, Cardiff CF4 3BL, United Kingdom.
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ISSN 1326-978X print/ISSN 1469-9532 online/00/01041-17 2 0 0 0 Australian Society for the Study of Intellectual Disability Inc.

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MedLine and which utilised the terms mental handicap, intellectual disability , mental retardation, aggression, violence, and restraint; this was extensively augmented with additional citations from books and journal articles. EPIDEMIOLOGY As with any epidemiological research, comparisons between epidemiological studies into the aggressive behaviour of people with intellectual disability are made difficult because of variations in the form of prevalence investigated and also because of variations in the operational definitions of key concepts. Thus, some available studies have concentrated entirely on interpersonal assault, while others have also included both verbal aggression and destruction of objects in their definition of aggression. Hence, differences in terminology can in themselves explain apparent differences in reported rates of aggressive behaviours. Prevalence may also vary according to the level of behavioural severity required to qualify for inclusion in a study sample (e.g., aggression which causes no injury versus aggression which results in tissue damage), the age profile of the sample (e.g. children versus adults), and the location of the study (e.g. institutional versus community based) (Borthwick-Duffy, 1994). Despite these difficulties, it is possible to abstract some key overall findings from the literature. The prevalence rate for aggressive behaviour in this client group appears to vary between 2-20% depending on the sampling procedures adopted (BorthwickDuffy, 1994; Harris & Russell, 1989; Quine, 1986; Sigafoos et al., 1994), higher rates will generally be found in males (Borthwick-Duffy, 1994; Davidson, Cain, SloaneReeves, Speybroech, Segel, Gutkin, Quijano, Kramer, Porter, Shoham, & Goldstein, 1994; Harris & Russell, 1989; Quine, 1986), and also in institutional settings (Borthwick-Duffy, 1994; Eyman & Call, 1977; Harris & Russell, 1989). Within the overall population of persons with intellectual disability, the prevalence of aggressive behaviour appears to increase with increasing severity of disability (Borthwick-Duffy, 1994; Davidson et al., 1994). Within the sub-population of people who challenge however, aggression is more likely to be shown by more able individuals (whereas self-injury is more prevalent amongst individuals with increased levels of disability) (Emerson et al., 1997). There appears to be a clear correlation between ratings of frequency and severity (Harris & Russell, 1989; Lowe & Felce, 1995); that is, aggression that occurs frequently is likely to be rated as posing more severe management problems. Although aggression may start early in life, rates tend to peak around late adolescence (presumably as the individuals concerned attain adult size and strength) (Davidson et al., 1994; Harris & Russell, 1993; Koller, Richardson, Katz, & McClaren, 1983). Aggression tends to coexist with other forms of challenging behaviour (Borthwick-Duffy, 1994; Emerson, Cummings, Barrett, Hughes, McCool, & Toogood, 1988; Harris & Russell, 1989; Sigafoos et al., 1994) and is also associated with the presence of mental health problems (Borthwick-Duffy, 1994). It tends to remain stable over time (Kiernan & Alborz, 1996; Lowe & Felce, 1995; Raynes & Sumpton, 1985), may often be episodic (i.e. it is of comparatively low frequency), but

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be potentially of high intensity (Harris & Russell, 1989; Sigafoos et al., 1994). Whilst most incidents of aggression seem to involve single punches, slaps and kicks, weapons may be used by between 17-29% of individuals who present with aggressive behaviours (Emersion et al., 1988; Harris & Russell, 1989; Sigafoos et al., 1994). The use of weapons in this population may not therefore appear to be as low as has sometimes been claimed (see, for example, McDonnell & Sturmey, 1993a). No information is generally available in the literature on the types of weapons used; this is a potentially serious omission as there are obviously significant differences in the risks posed by, for example, a small household object being thrown in anger and the malicious use of a knife. AETIOLOGY Numerous general models of aggressive behaviour exist (Bowie, 1996; Mulick, Hamer, & Dura, 1991; Peters, McMahon, & Quinsey, 1992), and most theories have attempted to identify motivational differences in aggressive behaviour. Moyer (1987), for example, describes four types of aggressive behaviour; instrumental aggression (which is goal directed, incentive led, and typically associated with low arousal), irritable aggression (which arises out of frustration and is associate with anger), sexual aggression (which is associated with sexual arousal), and fear-induced aggression (which essentially relates to the fight-flight scenario). There is no reason to presuppose that the basic factors that precipitate aggression in people with intellectual disability are any different from those which are relevant in the general population. The presence of an intellectual disability may, however, introduce additional risk factors that increase the probability of aggression. These factors can be viewed as setting conditions for aggression, and may be related both to individual characteristics and to characteristics of the environments in which people are typically supported. Gardner and Moffat (1990) describe a specific multi-component biopsychosocial model for the causation of aggression in people with learning disabilities which, although being essentially behavioural in nature, adopts a clear interactional stance that allows a wide range of causal factors to be taken into account. The model outlines four classes of factors that may be implicated in the generation of aggressive behaviour. These are concerned with environmental and personal risk factors that may set the scene for aggression to occur, and with learning processes through which aggression may be strengthened and maintained or weakened and reduced. These factors and the potential interrelationships between them will be briefly considered in turn. Individual setting conditions As outlined above, studies have shown that within the overall population of persons with intellectual disability, the prevalence of aggression increases with the severity of learning disability, a factor that has been interpreted as evidence of a causal association with neurological damage. Evidence from research on animal models has also shown

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that lesions within or stimulus of certain areas of the brain (such as the septum or hypothalamus) can induce aggression, and this body of research, together with evidence from studies on human subjects who displayed aggression subsequent to acquired neurological damage, has been cited as further evidence for organic causation (Davison & Neale, 1974; McCleary & More, 1965). Indeed, it is not difficult to construct a list of cognitive-behavioural sequelae (such as reduced attention span, poor impulse control, impaired memory, etc.) to the neurological damage inherent in intellectual disability that may indeed predispose towards this form of behaviour. Evidence that aggressive behaviour may fluctuate over long periods of time in discrete cycles (Lewis, Silva, & Silva, 1995) may also be indicative of the involvement of underlying neuro-physiological mechanisms such as natural variations in levels of serotonin or norepinephrine (Hagerman, Bregman, & Tirosh, 1998; Lewis et al., 1995). Other physiological factors which have been investigated with regard to their role in precipitating aggression in people with intellectual disability include epilepsy (Creaby, Warner, Jamil, & Jawad, 1993), acute or chronic pain, allergies, hormonal disorders (Gourash, 1986), pre-menstrual tension and disruption in the menstrual cycle (ODwyer, Holmes, & Friedman, 1995). While all these factors are equally relevant to the general population, the risk of such medical conditions remaining undetected and untreated is heightened in persons with intellectual disability (Welsh Health Planning Forum, 1992). Super-imposed psychiatric problems present similar diagnostic challenges, and it has been empirically demonstrated that psychiatric disorder is likely to be underdiagnosed in this population (Reiss, Levitan, & Szyszko, 1982). Depression, paranoia, psychosis or personality disorder may all be implicated in aggression within this group (Szymanski et al., 1998). Other broader psychological states (such as poor selfesteem) and reactions to life events (physical and sexual abuse, bereavement, and service transitions) may also play important roles as setting events (Royal College of Psychiatrists, 1995). People with intellectual disability may also display a variety of skill deficits which may increase the probability of aggression. General skill deficits which may be relevant include limitations in communication skills, social skills and general independent functioning. Other far more specific skill deficits may also exist. For example, Walz and Benson (1996) provided some experimental data illustratin g differences in the ability of aggressive and non-aggressive subjects with mild-borderline intellectual disability to discriminate between facial expressions of emotion. Aggressive subjects mislabelled both angry and sad expressions significantl y more than controls, and were more likely to apply the label anger when they were unsure of an emotion, thus suggesting a negative emotional bias for ambiguous expressions. Davidson et al. (1994) found that individuals who were destructive towards property but not people were more likely to be functioning at a higher cognitive level, possibly suggesting that higher functioning individuals may make use of their verbal and cognitive skills to limit their aggression. This would seem to be in conflict with the previously cited research by Emerson et al. (1997) which reported that aggression was associated with higher levels of ability within the sub-population of people with

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intellectual disability who challenge. Both studies suggest, however, that personal competence is a significant determinant of the specific forms of behaviour shown by challenging individuals . Environmental setting conditions It is rare in clinical practice to find isolated physical or psychological conditions under which aggression can be reliably predicted to occur. Typically, a complex combination of stimuli will set the scene for the occurrence of aggressive behaviour and this stimulus set frequently involves both internal and external drives and provocations . The latter may include the presence of a number of environmental pollutants such as excessive heat, noise, and overcrowding, together with other service related factors such as high turnover rates of younger age clients, inexperienced staff with poor and/ or inappropriate interactional styles, a lack of structured activity, the presence of aggressive models, and the intermittent reinforcement of aggressive behaviour, all of which have been identified in the literature as being environmental risk factors associated with aggressive behaviour in institutional settings in general (Blumreich & Lewis, 1993; Harris & Rice, 1992) and which are common features of many services for people with intellectual disability. While personal and environmental conditions may set the occasion for aggression to occur, its actual onset may be precipitated by far more discrete events. Thus, there are examples from the general psychiatric literature of aggression being triggered by nursing staff denying patients requests (Palmstierna, Huitfeldt, & Wistedt, 1991), general staff: patient exchanges (Colenda & Hamer, 1991), and a variety of aversive interactions from staff including approach or physical contact, frustration, activity demands, and negative verbal statements (Whittington & Wykes, 1996). In the learning disability literature, aggression has similarly been shown to be functionall y related to the occurrence of aversive social contacts (Carr, Newsom, & Binkoff, 1980; Carr, Taylor, & Robinson, 1991; Horner, Sprague, Day, Sprague, OBrien, & Heathfield, 1991). Maintaining variables Aggression that has been precipitated by individual and environmental factors and events will be maintained or decreased depending upon the responses which it generates. Thus, aggressive behaviour may be maintained and strengthened through positive reinforcement (e.g., by gaining access to preferred activities) or negative reinforcement (e.g., the reduction of aversive carer interactions). This is consistent with the social learning model of aggression which suggests that aggressive behaviour is acquired via modelling and reinforcement, and the aversive stimulation model whereby aggression is employed as a means of escaping from situations which the individual finds frustrating (Breakwell, 989). Aggressive behaviour may be weakened and reduced via extinction (the termination of previously available reinforcing consequences), positive punishment (e.g. via over-correction, electric shock) or negative punishment (e.g. via time-out or response cost).

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A number of authors (Carr, Robinson, & Palumbo, 1990; Gardner & Moffat, 1990; Horner, Dunlap, Koegel, Carr, Sailor, Anderson, Albin, & ONeill, 1990; LaVigna & Donnellan, 1986) have made the distinction between the treatment and the management of challenging behaviours in people with learning difficulties. Treatment aims to produce behavioural change that endures over time and generalises across relevant settings. It is likely to involve the modification of provocative environmental stimuli via ecological change, the introduction of new coping strategies to help the person manage both internal and external precipitants of aggression, and the development of adaptive responses that will serve to replace the aggressive actions. Management approaches, in contrast, focus on safe responding to aggressive behaviour when it occurs. Emergency or reactive management plans are not concerned with behaviour change, but simply with the safe and efficient management of out of control behaviours which represent a physical threat to the safety of the client and/ or others. Treatment and management approaches will be examined in turn. TREATMENT INTERVENTIONS Two main methods of intervention will be considered here, those based on behavioural models and those involving medication. These were selected because they currently represent the most common forms of intervention for aggressive behaviour in this population. While there is a developing interest in psychotherapy (Beal & Warden, 1996; Nuffield, 1986; Stavrakaki & Klein, 1986;) and cognitive-behavioural approaches (Kroese, Dagnan, & Loumidis, 1997) for problems such as aggression in people with intellectual disability, these areas are comparatively underdeveloped at present and not yet subject to adequate empirical scrutiny. They will therefore not be considered within the scope of this review. Behavioural treatment The bulk of clinical and research interest in terms of interventions for aggressive behaviour in persons with intellectual disability has undoubtedly been invested in behavioural approaches. A wealth of literature exists on this topic, and a number of extensive reviews are available which consider interventions for aggression either as a main or as a subsidiary topic (Carr, Robinson, Taylor, & Carlson, 1990; Scotti, Evans, & Walker, 1991; Guess, Helmstetter, Turnbull, & Knowlton, 1987; Matson & Gorman-Smith, 1986; Lennox, Mitlenberger, Sprengler, & Er-fanian, 1988; Scotti, Ujcich, Weigle, Holland, & Kirk, 1996; Didden, Duker, & Korzilius, 1997; Whitaker, 1993). There is clear evidence that behavioural techniques can be effective in changing aggressive behaviours. For example, the average percentage reduction from base-line in studies reviewed by Whitaker was 84%, while Scotti et al. (1991) found the mean per-centage non-overlapping data (PND) between treatment and comparison phases to be 67% for aggressive and tantrum behaviour combined. Didden et al. (1997) found a similar rate of 68% for percentage non-overlapping data for interventions focusing on aggression alone.

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While the general effectiveness of behavioural procedures is evident from these meta-analyses, ascertaining which particular techniques are most effective is far more problematic due to the comparatively small number of studies and subjects involved. Thus, while Scotti et al. (1991) found that environmental change, over-correction, and skill teaching were the most effective interventions for aggression according to the PND statistic, such conclusions must be viewed with caution at this stage. In any case, it may be argued that the efficacy of individual approaches is to some extent spurious in that the best technique for any given client is an individualised functional analysis which generates an individualised intervention option (Carr, Robinson, & Palumbo, 1990; Danforth & Drabman,1989). To date, comparatively little attention has been paid to potentially promising self-control procedures such as anger management (Benson, Rice, & Miranti, 1986; Black, Cullen, & Novaco, 1997). Whitaker (1993) draws attention to two specific areas where demonstrations of intervention effectiveness are lacking . These are where the aggression is of a fairly low frequency and where aggression occurs in family settings. Both factors are likely to be of considerable clinical significance. Aggressive behaviours may often occur at a comparatively low frequency (but high intensity), and aggression often emerges at an early age. It is therefore likely to first become manifest within family settings. Medication Numerous studies have shown that individuals with intellectual disability who display aggressive behaviour are likely to receive psychotropic medication (Fleming, Caine, Ahmed, & Smith, 1996; Harper & Wadsworth, 1993; Kiernan, Reeves, & Alborz, 1995; Linaker, 1984; Tu & Smith, 1983). Qureshi (1994) found while that 53% of people with intellectual disability who displayed aggressive behaviour were receiving drugs to control this behaviour, only 20% were reported to be receiving any form of behavioural intervention. Similarly, Harris, & Russell (1989) found that 55% of people whose aggression was reported to present extreme management difficulties received drug treatment for their behaviour, whereas only 17% were in receipt of behavioural interventions. These findings parallel those of Oliver, Murphy, and Corbett (1987) in relation to self-injurious behaviour. Taken at face value, these results would seem to suggest that medication clearly represents a more effective form of treatment for aggression than the behavioural procedures described above. However, Lennox et al. (1988) found medication to be the least effective intervention for aggression in terms of percentage change from baseline as compared to a variety of behavioural interventions, and questioned its continued use for behaviour problems in general in the absence of empirical evidence for clinical effectiveness. These results were echoed by Didden et al. (1997). Neuroleptics (anti-psychotics) appear to be the most commonly used medications for the control of aggression and other challenging behaviours (Aman & Singh, 1991; Poling, Gadow, & Cleary, 1991). Aman & Singh (1991) report that there are few wellcontrolled studies from which clear conclusions could be drawn to support this prescribing practice however. This view is supported by Baumeister, Sevin, and King (1998) who stated that, while there is some fairly strong evidence for the efficacy of

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neuroleptics in relation to stereotypies, the evidence was less compelling with regard to aggression and other forms of challenging behaviour (p.144). All too often it is apparent that, rather than being prescribed for any specific therapeutic effect (that is, to treat underlying psychiatric states which may precipitate or predispose towards aggressive outbursts), anti-psychotic medication is frequently applied as a general behavioural suppressant in the absence of any diagnosis of functional mental illness (Fleming et al., 1996). Numerous other drugs have also been used for aggression. The consensus at present is that beta-blockers may be helpful for aggression which is not attributable to any specific psychiatric disorder (Fraser et al., 1998), and that buspirone may be indicated where the aggression is associated with elevated anxiety levels (Werry, 1998). Poindexter et al. (1998) note that Lithium can have an anti-aggressive effect in addition to its specific effect on mood. Finally, several studies have indicated the potential benefits of utilising carbamazepine for aggression, and have reported that such benefits do not appear to be due to simple sedation (Kennedy & Meyer, 1998). Clarke (1999) suggests that its use is particularly indicated in the case of impulsive aggression and that, not surprisingly, it is particularly effective if there is evidence of an abnormal E.E.G. pattern. Sobsey (1989) states that when evaluating the potential benefits of medication, clinicians must distinguish between the benefits for the client and the benefits for the carers; he points out that there are no legal or ethical rationales for prescribing on the basis of the latter. The same argument could, of course, apply to behavioural techniques, as it is sometimes questionable as to whose needs are being served with the application of procedures such as time-out or response cost. One possible explanation for the bias towards the use of medication over behavioural approaches in clinical practice may be that the former require considerably less investment of carer time and effort than the latter. As with behavioural interventions, it is therefore vital that drug studies demonstrate significant changes in quality of life as well as changes in behaviour (Poling & LeSage, 1995), particularly in view of the fact that psychotropi c use is associated with a range of harmful side effects (Aman & Singh, 1991) which have been described as varying between annoying and distressing to permanently debilitating (Schall & Hackenburg, 1994, p. 124). Many of the above concerns are addressed within the recent International Consensus Handbook on the use of psychotropic medication with people who have developmental disabilities (Reiss & Aman, 1998) which included the statement that:
Psychotropic medication shall not be used excessively, as punishment, for staff convenience, as a substitute for meaningful psychosocial services, or in quantities that interfere with an individuals quality of life. (p.52)

While there is evidence for the effectiveness of various forms of medication for short-term behavioural reduction, the most constructive use of drugs would appear to be in the creation of a window of opportunity for the introduction of behavioural methods (Gardner & Moffat, 1990; Lapierre & Reesal., 1986; Schaal & Hackenberg, 1994; Schalock, Foley, Toulouse, & Stark, 1985; Sovner & Hurley, 1986; Thompson, Egli, Symons, & Delaney, 1994). This point will be considered further in the concluding section of this review.

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Irrespective of whether behavioural or pharmacological interventions are employed, the complete elimination of aggressive behaviour is an unlikely outcome. Carers of aggressive individuals, even those who have been the subject of successful therapeutic regimes, will therefore periodically be faced with out of control behaviours from which both they and the client may need to be protected. Failure to adequately prepare carers to cope with such behaviours may, as already stated, inflate service costs and could also result in prosecutions under Health and Safety legislation (Health & Safety Executive, 1994). Procedures for responding to aggression and other forms of challenging behaviour have been collectively described as reactive management strategies (LaVigna, Willis, & Donnellan, 1989). Reactive management strategies are not treatments, and are therefore not concerned with changing behaviour, but only with the safe and efficient management of out of control behaviours. At their least intrusive level, they may consist of strategies to defuse potentially aggressive incidents via verbal., non-verbal and distraction techniques. At their most intrusive, they may involve self-defence techniques (often referred to as breakaways), emergency physical restraint (as opposed to the planned use of restraint as an aversive consequence in a behavioural intervention), emergency medication, and seclusion (Harris, 1996; Harvey & Schepers, 1977; Mason, 1996; Willis & LaVigna, 1985). There is evidence that planned reactive strategies are, not surprisingl y, less risky than un-planned reactive strategies (Hill & Spreat, 1987; Spreat, Lipinski, Hill, & Halpin, 1986), that staff can be effectively trained in these procedures (McDonnell, 1997; van den Pol, Reid, & Fuqua, 1983), and that such training can have a variety of positive outcomes which include reduced rates of assaultive behaviour, lower levels of injury to staff and clients, and reduced frequency of use of emergency medication (Allen, McDonald, Dunn, & Doyle, 1997; Infantino & Musingo, 1985; Mortimer, 1995). The most prevalent form of training in this area within the United Kingdom is Control & Restraint (recently renamed, rather euphemisticall y, as Care & Responsibility). It consists of a set of procedures originally developed within the prison service and subsequently passed down into the general psychiatric and learning disability services via the special hospitals (Special Hospitals Service Authority, 1992). The methods used in this system reflect its origins, and are dependent for their effectiveness on inflicting a degree of pain on the person being restrained etc. in order to achieve compliance. Control & Restraint techniques are undoubtedly effective, however, as the Royal College of Psychiatrists (1995) have observed:
There must be grave concern that the widespread and deliberate use of pain, whether actual or threatened, has become part of the management of patients without consideration as to the moral and ethical issues involved. There is no evidence in the literature that the use of pain in Control and Restraint has been examined to determine its relevance. Its role becomes particularly problematic and hazardous where the patients perception of pain is altered (as might occur with learning disability, autism or various psychiatric states). (Royal College of Psychiatrists, 1995, p.6)

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The method has also been criticised in its application to persons with intellectual disability (Doyle, Dunn, Allen, & Hadley, 1996) on the grounds that its techniques do not match the typical assault pattern shown in this group, that it is likely to be unacceptable within community settings (an increasingly important consideration with the drive to accommodate more challenging individuals in non-institutiona l settings), and that it is impractical to implement within the staffing ratios in many services. The same authors also question the wisdom of teaching aggressive techniques to staff working with clients who are known to be at greater risk of carer abuse (Marchetti & McCartney, 1990; Rusch, Hall, & Griffin, 1986), with behaviours which are likely to produce strong emotional responses from carers (Bromley & Emerson, 1995), and within environments which have a history of supporting abusive practices (Martin, 1984). In addition, if effective methods which were not dependent upon pain for managing the aggressive behaviour of people with intellectual disability could be demonstrated, pain-compliance methods could be viewed as illegal in that they would fail to comply with the principle of minimum force and, in the absence of consent, could technically be regarded as assault. Several alternative approaches which do not inflict pain, and which meet the joint requirements of effectiveness and acceptability (McDonnell & Sturmey, 1993a; McDonnell, Sturmey, & Dearden, 1993) are in fact now available. The training procedures described by a variety of authors (Cornick, Holt, & Bromley, 1996; Dempster, Tucker, Warnick, Fogarty, & Attwood, undated; Doyle, Dunn, Allen, & Hadley, 1996; McDonnell, Dearden, & Richens, 1991 a, b, c; New York State Office of Intellectual Disability & Developmental Disabilities, 1988), whilst having different origins and emphases, contain many common principles including a major focus on preventative approaches, the use of a gradient of techniques which are tailored to the severity of the behavioural incident, and strict rules to govern the prescription and monitoring of technique use. Recently, guidelines have been produced which aim to enable organisations to construct their own reactive management policies which meet these good practice points (Harris, Allen, Cornick, Jefferson, & Mills, 1996). Extensive guidance is also available on the legal issues which surround the use of reactive procedures with children who have intellectual disability and challenging behaviour (Lyon, 1994). Despite the importance of this area, there is some evidence to indicate that significant numbers of carers receive no training of this sort. Harris and Russell (1989), for example, found that under 40% of carers of clients rated as posing extreme management problems had received training in restraint despite the fact that over half their clients had been restrained at least once in a four week period. Similarly, Allen and Hill-Tout (1999) found that few staff supporting people with challenging behaviour in day services received training in restraint techniques and were often left to determine physical intervention methods for themselves. CONCLUSIONS Aggressive behaviour clearly represents a significant management problem in working with people who have intellectual disability. Four major conclusions emerge from

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the present review. These concern the nature of assessment, the potential for combining behavioural and pharmacological interventions, the need to demonstrate the social validity of behaviour change strategies, and the need to develop effective aggression management procedures. Assessment Aggressive behaviour is likely to be the product of a complex combination of personal characteristics, environmental setting conditions and specific antecedents. All too often, assessments of aggression tend to focus on molecular levels variables (i.e. temporally limited stimulus-response-stimulus relationships) to the relevant exclusion of more molar assessments of person-environment fit. Comprehensive behavioural assessment needs to focus on both molar and molecular variables (Carr et al., 1998). More restrictive assessments increase the probability of interventions being unsuccessful or of their attending to the wrong behaviours. More effective assessments will therefore set the scene for more effective interventions . Developing optimum intervention s A significant body of research exists to support the clinical effectiveness of behavioural interventions for aggression in this client group. Although there is considerably less empirical support for the use of medication, it is the use of psychotropic drugs which tends to dominate in clinical practice. Given the likelihood that challenging behaviours such as aggression may be both environmentally and internally motivated, optimum interventions are likely to need to combine both chemical and behavioural elements (Thompson et al., 1994). As with behavioural intervention, medication prescribing must be functional, with decisions about which medications to employ being taken on the basis of empirical research on specific drug actions, and following a behavioural and neurochemical analysis of behavioural function. Most drug trials report a percentage of clients whose behaviour fails to respond to chemical intervention. Just as with environmentall y motivated behaviours, this may be because the behaviour of the non-respondin g individuals is driven by different neurochemical functions. Current prescribing of medication for behavioural difficulties often resembles a poorly-monitored stab in the dark, and a specific research task is therefore to identify variables which predict treatment outcome (Thompson et al., 1994). It is already possible to construct theoretical accounts of how dual drug-behavioura l interventions might work. Evidence from research on animal models (Kennedy & Meyer, 1998; Schaal & Hackenburg, 1994) suggests that neuroleptics may act specifically to reduce the behavioural avoidance of aversive events. This being the case, neuroleptic medication may have beneficial short-term effects for a person whose high intensity physical aggression had been shown to be functionally related to the presentation of demands from carers. The prescription of an anti-psychotic could be paired with behavioural strategies such as ecological changes that lowered the rate and degree of complexity of demands in the short-term; functional communication training that taught the person more socially appropriate methods of terminating demands which they perceived to be aversive; instruction in self-control strategies for use when

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aversive demands were presented; and the gradual reintroduction of more aversive (but socially valid) demands via a process of desensitisation. How such combined pharmacological- behavioural interventions might work in practice needs to be a clear focus of future research activity. Demonstrating social validity A final major concern regarding the intervention literature is the failure to report data that support the social validity of treatments. Emerson (1995) argues that intervention s need to demonstrate social validity on the basis of showing that they are addressing a socially significant problem, that they are undertaken in such a way as is acceptable to the main stakeholders involved, and that they result in socially important outcomes or effects. Whilst behavioural studies are showing a gradual improvement in this respect, social validity data have been almost totally absent from drug studies (Poling & LeSage, 1995). A particularly important point to note regarding the social validity of behavioural or pharmacological interventions is that, given the often inappropriate and dysfunctional environments within which many persons with intellectual disability are forced to live, their expressions of anger and aggression may be viewed as a legitimate response to unacceptable conditions. This being so, interventions must focus on modifying these conditions as well as on modifying reactions to them in order to achieve ethical stringency. In this sense, improving quality of life is a treatment intervention as well as a treatment objective (Scotti et al., 1996). Reactive behaviour management As reported in the text, the safe management of aggressive behaviour is a key concern for services but, despite the availability of a number of ethically sound approaches, there is scant evidence to indicate that carers are receiving training in this area. This is a major omission, and recommendations for safe management need to be viewed as an essential component within intervention packages. While further research is required to identify optimum techniques for client and carer safety, this needs to be combined with initiatives to raise services awareness of the importance of this area. The latter will almost certainly be driven more by legal requirements than by scientific study. As with intervention approaches, the demonstration of social validity is a critical requirement for reactive strategies (McDonnell & Sturmey, 1993b).
Acknowledgement My thanks are due to Dr. Eithne Buchanan-Barro w, University of Surrey, Guildford, Surrey, GU2 5XH, U.K., for her comments on an earlier draft of this paper.

Physical aggression REFERENCES

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