In order to examine the importance of a range of potential risk factors for behaviour problems in children with severe intellectual disability, a sample was identified by the administration of a screening version of the Vineland Adaptive Behaviour Scales (VABS) to the parents of children aged 4-11 years attending six special needs schools in three adjacent inner London boroughs. Parents whose children had a VABS standard score of < or = 50 were interviewed using the Disability Assessment Schedule and both parents and teachers completed the Aberrant Behaviour Checklist. Most behaviour problems were more common in ambulant children, but problems less dependent on the ability to walk, such as sleeping difficulties, screaming and self-injury, were equally common in ambulant and non-ambulant children. Among ambulant children, there were few significant associations between the severity of the child's behaviour problems and the age or sex of the child, the presence or absence of epilepsy, and various indices of socio-economic disadvantage. Sleeping difficulties, overactivity, self-injury, destructive behaviour and autistic features, such as social withdrawal and stereotypies, were strongly associated with skills deficits, but aggression, temper tantrums and general disruptive behaviour were not. Limitations in daily living skills were better predictors of behaviour problems than were poor communication skills.

Optimal dosing of methylphenidate is practical and effective in some children with hyperkinetic disorder and intellectual disability. Adverse effects typical of methylphenidate were seen and medication use may require close monitoring in this vulnerable group.

Need for, and receipt of, respite care services were examined in a representative sample of 103 5±11-year-old children with severe intellectual disability and their families. Children for whom respite care was wanted had signi®cantly more severe disabilities and behaviour problems than those whose parents felt they did not need it; their parents also reported signi®cantly higher levels of stress. However, among those who wanted respite care, none of these factors appeared relevant to whether or not they had received it. The results suggest the need for greater account to be taken of the severity of the child's behaviour problems and intellectual disabilities in the allocation of respite care services, and also for measures to improve the supply of respite care placements capable of managing children with more challenging behaviour.

SummaryMedications, particularly antipsychotics, are commonly used to manage challenging behaviour in people with intellectual disability. When the behaviour does not arise from an underlying mental illness, this is commonly off-licence and evidence of efficacy is lacking. A national audit programme would be one way to address the concerns this raises.

The artwork in this booklet was produced by people with neurodevelopmental disorders who required hospital treatment at the Bethlem Royal Hospital, South London and Maudsley NHS Foundation Trust. It has been reproduced with their permission. Art can be an important communicative and therapeutic tool for people who find verbal communication difficult. All of the artists wished to remain anonymous except for Victor who produced the art on pages 2, 30, 36, 42, 46 and 52. About Us Educational opportunities for medical students, core trainees and higher psychiatric trainees in neurodevelopmental psychiatry are delivered through the Behavioural and Developmental Psychiatry Clinical Academic Group (B&D CAG) at the South London and Maudsley NHS Foundation Trust (SLaM). We provide mental health services for adults with neurodevelopmental disorders and for those who require enhanced risk management or secure inpatient services, working with people nationally and internationally. Editors Simon Bonell MRCPsych Dr Bonell recently completed his higher psychiatric training in the psychiatry of learning disabilities with SLaM. During the production of this booklet he moved to take up a substantive consultant post in Plymouth.