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Background In an era of evidence-based medicine, practice is constantly monitored for quality in accordance with the needs of clinical governance (Oyebode et al. ). This is likely to lead to a dramatic change in the treatment of those with intellectual disability (ID), in which evidence for effective intervention is limited for much that happens in ordinary practice. As Fraser (, p. ) has commented, the word that best explains 'the transformation of learning disability practice in the past  years is "enlightenment".' This is not enough to satisfy the demands of evidence, and Fraser exhorted us to embrace more research-based practice in a subject that has previously escaped randomized controlled trials (RCTs) of treatment because of ethical concerns over capacity and consent, which constitute a denial of opportunity which 'is now at last regarded as disenfranchising'. Conclusions The present paper describes the difficulties encountered in setting up a RCT of a common intervention, i.e. assertive community treatment, and concludes that a fundamental change in attitudes to health service research in ID is needed if proper evaluation is to prosper.Keywords assertive treatment, evidence-based practice, randomized controlled trial IntroductionThe significant shift from hospital to community with the introduction of specialist services (Farmer et al. ) has influenced intellectual disability (ID) in the past  years. Three key changes are: () the introduction of 'care management', i.e. the creation of packages of care, primarily of a social, educational, and developmental nature; () transfer of 'physical care' to primary healthcare; and () concentration of 'mental health' in specialist health services. These changes should be based on evidence; the present paper shows some of the difficulties of obtaining this. The initial evidence base for these changes was provided by research in the s at the Fountain Hospital Queen Mary's, Carshalton, Surrey, UK, where Tizard () demonstrated that children with severe ID brought up in small, personalized groups developed better intellectual and social skills than those remaining in large hospitals, where recurring scandals (Townsend ) led to public shame.The changes recommended included closing large hospitals and setting up small living groups with a social developmental approach. This concept of normalization (Woolfensberger ) took a powerful hold, but only a few services attempted adequate evaluation (Felce ; Felce & Perry ).To evaluate smaller, locally accessible services, we need to have common health components and outcomes (DoH ). It is well documented that the prevalence of mental disorders in people with ID is complex and difficult to determine (Russell ). There is continuing debate with relation to whether behaviour disorder constitutes an environmental problem or developmental disorder (Russell ). The two frequently used terms, i.e. challenging behaviour and dual diagnosis, denote different classificatory con...

Although "intellectual disability" has widely replaced the term "mental retardation", the debate as to whether this entity should be conceptualized as a health condition or as a disability has intensified as the revision of the World Health Organization (WHO)'s International Classification of Diseases (ICD) advances. Defining intellectual disability as a health condition is central to retaining it in ICD, with significant implications for health policy and access to health services. This paper presents the consensus reached to date by the WHO ICD Working Group on the Classification of Intellectual Disabilities. Literature reviews were conducted and a mixed qualitative approach was followed in a series of meetings to produce consensus-based recommendations combining prior expert knowledge and available evidence. The Working Group proposes replacing mental retardation with intellectual developmental disorders, defined as "a group of developmental conditions characterized by significant impairment of cognitive functions, which are associated with limitations of learning, adaptive behaviour and skills". The Working Group further advises that intellectual developmental disorders be incorporated in the larger grouping (parent category) of neurodevelopmental disorders, that current subcategories based on clinical severity (i.e., mild, moderate, severe, profound) be continued, and that problem behaviours be removed from the core classification structure of intellectual developmental disorders and instead described as associated features.

BackgroundThough contentious, the diagnosis of personality disorders in persons with learning disability is clinically relevant because it affects many aspects of management.AimsTo examine published literature on the diagnosis of personality disorders in learning disability.MethodSelective review with computerised (Medline, Embase and PsychInfo) and manual literature searches.ResultsThe variation in the cooccurrence of personality disorder in learning disability, with prevalence ranging from less than 1% to 91% in a community setting and 22% to 92% in hospital settings, is very great and too large to be explained by real differences.ConclusionsThe diagnosis of personality disorders in learning disability is complex and difficult, particularly in those with severe disability Developing consensus diagnostic criteria, specific for various developmental levels, is one way forward. Such criteria may need to include objective proxy measures such as behavioural observations and informant accounts.

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