Behavioural/cognitive-behavioural interventions in aggressive challenging behaviour

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The Cochrane collaboration gathers and summarises evidence from randomised controlled trials (RCTs) to support better clinical decision making. The collaboration is an independent network of researchers, professionals, patients, carers, and people interested in health and there are a number of subject specific review groups.

The group on developmental, psychosocial and learning problems has published a number of reviews relevant to the support of people with learning disabilities and this latest, looks at the RCT evidence on behavioural and cognitive-behavioural interventions for outwardly-directed aggressive behaviour. We recently posted about the NICE guidelines for people with challenging behaviour.

The current paper is an update of an existing Cochrane review which was carried out in 2002 and last updated in 2013. The authors were interested specifically in looking at RCT evidence from studies that looked at whether behavioural and cognitive-behavioural therapies were more effective in reducing aggressive behaviour in adults and children with learning disabilities, compared to what happened for control groups receiving no intervention.

The authors spend some time in defining challenging behaviour, pointing out that whilst it is not a diagnostic entity in itself, it is considered a potential co-morbidity in people with learning disabilities. The International Classification of Diseases (ICD-10) also provides a diagnostic code, not only for ’Repetitive Self Injury’, but also ’Aggression towards Other’.

They point to the potential impact of severe challenging behaviour on the individual, their family and their supporters.

They suggest though that much of the research published which looks at the different types of interventions to help manage challenging behaviour is in the form of single-case reports or small scale studies with little data on long-term clinical outcomes or economic costs of interventions.

Where reviews of interventions have looked at treatment efficacy, some key messages have emerged:

  • formal functional analysis of behaviour prior to treatment may improve clinical outcomes.
  • aggressive behaviour was less amenable to treatment when compared to self injury or socially disruptive behaviours


Challenging behaviour can have a significant impact on quality of life for the person, their family and supporters

Challenging behaviour can have a significant impact on quality of life for the person, their family and supporters


The Cochrane review group have published their search strategy as part of the review. They ran electronic searches of relevant databases as well as handsearching journals and reference lists of articles retrieved,

They were looking for randomised controlled trials (RCTs) or quasi-randomised controlled trials (q-RCTs) which reported on interventions for children and adults with intellectual disabilities (mild-to-severe/ profound) who exhibit aggressive behaviour.

They were interested in studies that reported on the following interventions:

  • Behavioural modification interventions, e.g. differential reinforcement of other behaviour (DRO); applied behavioural analysis (ABA); positive behaviour support (PBS);
  • Cognitive-behavioural treatment, e.g. anger management, problem-solving skills training, relaxation, and meditation or ’mindfulness’.

They used GRADE to assess the quality of evidence for each outcome


Results of the most recent update identified six trials that met the criteria for inclusion.

The studies involved a total of 309 participants and looked at a range of cognitive-behavioural therapy (CBT) approaches:

  • anger management
  • relaxation
  • mindfulness based on meditation
  • problem solving
  • assertiveness training

There were no studies of children.

In terms of the GRADE approach, only one study reported moderate quality of evidence for outcomes. The other studies were judged as ‘very low’ to ‘low’ quality.

The authors also suggest that most of the studies were at risk of bias through not randomly allocating participants (or not making clear the process of randomisation) not blinding assessors or not offering a complete presentation of outcomes.

However, they report three of the six studies showing some benefit in improving anger ratings. Only one of the studies had adequate long-term data (10 months). This showed some benefit as rated by key workers.

Two studies of the studies reported some evidence of the intervention involved reducing the number of incidents of aggression.

One of the six studies also looked at quality of life and cost of health and social care utilisation and suggested that compared to no treatment, behavioural or cognitive-behavioural interventions did not improve quality of life at 16 weeks, at 10 months follow-up, or reduce the cost of health service utilisation.

Interestingly, there was no reporting of adverse effects in any of the six studies.

Five of the six studies included showed some improvements in outcomes for people, but there were few data on longer term outcomes

Five of the six studies included showed some improvements in outcomes for people, but there were few data on longer term outcomes


Unsurprisingly, the authors conclude that the

existing evidence on the effectiveness of behavioural and cognitive-behavioural interventions on outwardly-directed aggression in children and adults with intellectual disabilities is limited.”

Their comprehensive search found few methodologically sound clinical trials and where these were reported, there was little long term follow up on clinical outcomes.

They recommend that

randomised controlled trials of sufficient power are carried out using primary outcomes that include reduction in outward-directed aggressive behaviour, improvement in quality of life, and cost effectiveness.”

Strengths and Limitations

As ever, the search strategy is comprehensive and fully published and the interventions under consideration are clearly defined and described and the approach to grading evidence and identifying potential biases is clear.

The trials found were quite small in terms of participants. Indeed the overall number of people involved was just over 300.


This Cochrane review looked specifically at whether behavioural and cognitive-behavioural therapies are more effective in reducing outwardly directed aggressive behaviour in adults and children with intellectual disabilities, compared to no intervention as investigated by randomised controlled trials with control groups.

Whilst there were improved outcomes for people in receipt of behavioural and cognitive-behavioural therapies reported in five of the six included studies, there were few if any long term outcomes evaluated.

The studies were small and the quality of the evidence (as rated using GRADE) was from very low to moderate quality.

So, it is difficult to draw any clear conclusion from the current state of the evidence and the group call for some larger, good-quality studies with longer-term follow-up data.

Cochrane review finds limited evidence from small scale studies with potential biases, and recommends larger RCTs with longer term follow-up

Cochrane review finds limited evidence from small scale studies with potential biases, and recommends larger RCTs with longer term follow-up


Primary paper

Ali A, Hall I, Blickwedel J, Hassiotis A. Behavioural and cognitive-behavioural interventions for outwardly-directed aggressive behaviour in people with intellectual disabilities. Cochrane Database of Systematic Reviews 2015, Issue 4. Art. No.: CD003406. DOI: 10.1002/14651858.CD003406.pub4 [abstract]

Other references

McPhail CH, Chamove AS. Relaxation reduces disruption in mentally handicapped adults. Journal of Mental Deficiency Research 1989;33(5):399–406.

Nezu CM, Nezu AM, Arean P. Assertiveness and problemsolving training for mildly mentally retarded persons with dual diagnoses. Research in Developmental Disabilities 1991; 12(4):371–86.

Singh NN, Lancioni GE, Karazsia BT, Winton ASW, Myers RE, Singh ANA, et al. Mindfulness-based treatment of aggression in individuals with mild intellectual disabilities: a waiting list control study. Mindfulness 2013;4(2):158–67.

Taylor JL, Novaco RW, Gillmer BT, Robertson A, Thorne I. Individual cognitive-behavioural anger treatment for people with mild-borderline intellectual disabilities and histories of aggression: a controlled trial. British Journal of Clinical Psychology 2005;44(3):367–82.

Willner P, Jones J, Tams R, Green G. A randomised controlled trial of the efficacy of a cognitive-behavioural anger management group for clients with learning disabilities. Journal of Applied Research in Intellectual Disabilities 2002;15(3):224–35.

Willner P, Rose J, Jahoda A, Kroese BS, Felce D, Cohen D, et al. Group-based cognitive-behavioural anger management for people with mild to moderate intellectual disabilities: cluster randomised controlled trial. British Journal of Psychiatry 2013;203(4):288–96.

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John Northfield

After qualifying as a social worker, John worked in community learning disability teams before getting involved in a number of long-stay hospital closure programmes, working to develop individual plans for people moving into their own homes. He worked for BILD, helping to develop the Quality Network and was editorial lead for the NHS electronic library learning disabilities specialist collection. This led him to found the Learning Disabilities Elf site with Andre Tomlin as a way of making the evidence accessible to practitioners in health and social care. Most recently he has worked as part of Mencap's national quality team and also been involved in a number of national website developments, including the General Medical Council's learning disabilities site.

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