Intensive support teams for adults with intellectual disabilities displaying challenging behaviour: the IST-ID mixed-methods study

Abstract

Background National policy recommends intensive support teams for all areas of England for adults with intellectual disabilities who display challenging behaviour. However, to the best of our knowledge, there has not been a systematic evaluation of intensive support teams to date. Objectives Our objectives were to identify and describe the geographical distribution and characteristics of intensive support teams in England; to create a typology of intensive support teams; to investigate clinical and cost outcomes of intensive support team models and factors associated with those outcomes; and to explore professionals’, service users’ and carers’ experiences and describe the wider system context in which they operate. Design This was a two-phase mixed-methods study. In phase 1, a national survey examined the intensive support team models in operation in England. In phase 2, an observational study of adults with intellectual disabilities investigated the clinical effectiveness and cost-effectiveness of the two intensive support team models. Semistructured interviews with intensive support team managers and professionals, carers, and adults with intellectual disabilities explored their experiences of intensive support team care. In parallel, we examined service-level outcomes related to the function of intensive support teams. Setting Phase 1 included 80 intensive support teams serving 242 community intellectual disability services in England. Phase 2 included 21 intensive support teams, half of which were in the enhanced intensive support teams model and half of which were in the independent model. Participants In phase 1, a total of 73 intensive support team managers provided data. In phase 2, a total of 226 participants with intellectual disabilities from 21 intensive support teams (enhanced: teams, n = 11; participants, n = 115; independent: teams, n = 10; participants, n = 111) were enrolled in the study. A total of 42 stakeholders were interviewed. Main outcome measure The main outcome measure was the Aberrant Behaviour Checklist-Community, version 2, total score. Additional data sources were the carer and self-reported questionnaires, qualitative interviews and focus groups. Results Two intensive support team models were identified in England – enhanced and independent. Challenging behaviour at 9 months was reduced in both intensive support team models (β 3.08, 95% confidence interval –7.32 to 13.48; p = 0.561), but the observed Aberrant Behaviour Checklist-Community, version 2, score reduction appeared larger in the independent model than in the enhanced model (21% vs. 13%, respectively). No statistically significant differences were found in the secondary outcomes [Psychiatric Assessment Schedule for Adults with Developmental Disabilities Clinical Interview organic condition (odds ratio 1.09, 95% confidence interval 0.39 to 3.02), affective or neurotic disorder (odds ratio 0.91, 95% confidence interval 0.32 to 2.59), or psychotic disorder score (odds ratio 1.08, 95% confidence interval 0.21 to 5.50); risk score (β 1.12, 95% confidence interval –0.44 to 2.68); or quality of life questionnaire score (β –2.63, 95% confidence interval –5.65 to 0.40)]. Similarly, no differences were observed between models in relation to cost-effectiveness (health and social care costs mean difference £3409.95, 95% confidence interval –£9957.92 to £4039.89; societal costs mean difference –£4712.30, 95% confidence interval –£11,124.85 to £2106.36). The experiences of stakeholders did not differ between the intensive support team models, with carers and adults with intellectual disabilities valuing service accessibility, person-centred care and engagement. All stakeholders reported a range of barriers to intensive support team care. Service-level data and the operational policies from intensive support teams showed variation in organisational function and the roles of intensive support teams. The most commonly delivered intervention was positive behaviour support. Conclusions The study describes the operation of intensive support teams in England and identified two distinct models. We did not find advantages or disadvantages associated with clinical outcomes between models, nor did we find cost differences. On this basis, we recommend that local services decide which model best suits their circumstances. Limitations This was not a randomised controlled trial. It is possible that confounding factors have not been controlled for as there was no matching between intensive support teams. Last, there was no comparison with usual care. Future work There is need to develop model fidelity and investigate clinical effectiveness and cost-effectiveness in a randomised controlled evaluation of intensive support teams against treatment as usual. Study registration This study is registered as ClinicalTrials.gov NCT03586375, Integrated Research Application System (IRAS) 239820 and National Institute for Health and Care Research (NIHR) Central Portfolio Management System (CPMS) 38554. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 33. See the NIHR Journals Library website for further project information.

The effectiveness of positive behaviour support in reducing challenging behaviour and increasing quality of life for individuals with intellectual disability

“…ISTs are often poorly understood and defined (Hassiotis et al , 2020). Hassiotis et al (2020) identified two main models of IST, enhanced and independent, but they did not find a difference in outcome between the models (Hassiotis et al , 2022). This study contributes to an understanding of the role of ISTs by describing the processes and interventions of one team.…”

“…Essentially, one factor would answer "why" one variable affects the other, and this mechanism could produce a mediating effect. Hassiotis et al (2022) have compared enhanced and independent ISTs, but the specific impact of professional composition on outcomes for service-users has not been evaluated. Some ISTs are comprised entirely of psychologists and assistant psychologists, whereas others include psychologically trained members as part of the multidisciplinary team.…”

Stakeholder perspectives on intensive support teams for adults with intellectual disabilities who display behaviour that challenges in England

“…This is the first study in our knowledge to explore the views and experiences of multiple stakeholders of IST care in England. This qualitative study is part of a wider research programme that provided an overview of the current operation of ISTs and evaluated the clinical and cost effectiveness of two IST models in England (Hassiotis et al, 2021, 2022). Findings suggest that ISTs are often well received by family and paid carers and adults with intellectual disabilities.…”

“…This study is focused on ISTs that operate principally to address behaviour that challenges rather than mental ill health in adults with intellectual disabilities. It is part of a multicentre evaluation study of the two models of IST care operating in England (Hassiotis et al, 2021(Hassiotis et al, , 2022.…”

Who is at risk? Adults with intellectual disability at risk of admission to mental health inpatient care

“…For decades, reports have recommended the use of intensive support teams to manage behavioural crises in the community, prevent inappropriate admissions to mental health hospitals and facilitate discharge (Mansell, 2007; NHS England, 2015c). There are increasing numbers of intensive support teams in the United Kingdom, and they liaise with other services such as mental health teams, forensic community services, social care and commissioning teams (Hassiotis et al, 2022). Community forensic support teams were also recommended to support people who are at risk of coming into contact with the criminal justice system (NHS England, 2015c).…”