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Challenging and Inappropriate Sexual Behaviour in People with Learning Disabilities: A Literature Review - Research Findings

DescriptionThis research provides a review of recent research literature and the guidance available to agencies.
ISBN
Official Print Publication Date
Website Publication DateDecember 24, 1998
Social Work Research Findings No. 26
Challenging and Inappropriate Sexual Behaviour in People with Learning Disabilities: A Literature Review
ISBN 0 7480 7178 4Publisher The Scottish Office, 19981998
In recent years, concern has been expressed about the effectiveness of responses to challenging and inappropriate sexual behaviour in people with learning disabilities. The Scottish Office Social Work Services Group commissioned this review of recent research literature and the guidance available in agencies providing a service to this client group in Scotland.
Main Findings
  • Both challenging and inappropriate behaviour can have diverse causes, which can be identified through functional analysis of antecedents, behaviour and consequences which can assist in identifying the most appropriate intervention. Behavioural approaches are most often used in efforts to reduce both types of behaviour.
  • The quality of research on responses to challenging and inappropriate sexual behaviour varies considerably, with most studies being based on only a few cases. Evidence from studies is therefore suggestive rather than conclusive.
  • Further research is required to assess the effectiveness of different methods of carrying out functional analysis. Research is also required to look at the effectiveness of different behavioural approaches for different types of clients and the impact of aspects of service provision on reduction of challenging and inappropriate sexual behaviour.
  • Of those agencies which had policies and guidelines on challenging and sexual behaviour/abuse, the focus tended to be on short-term responses to incidents of violence, or to allegations of sexual abuse, rather than on long-term behavioural interventions.
  • Research suggests that in cases of sexual abuse of people with a learning disability, the level of police involvement is generally low.
  • Police find it difficult to identify people with learning disabilities and an effective method of identification has not yet been developed. Alleged offenders who have learning disabilities have difficulty in understanding their rights during police interviews and may require the presence of an appropriate adult.
Introduction
In recent years, concern has been expressed about the effectiveness of responses to challenging and sexually inappropriate behaviour in people with learning disabilities. The Scottish Office Social Work Services Group commissioned a review of recent research literature and guidance available in Scotland in the autumn of 1996.
The objectives of the literature review were:
  • to describe and assess the quality of evidence from recent research relevant to the challenging and inappropriate sexual behaviour in this client group;
  • to comment on the extent to which current literature adequately addresses the issues surrounding these behaviours;
  • to describe current policy and practice guidance documents relating to responses to these behaviours, including the extent to which these are consistent between different organisations and agencies;
  • to compare the findings of research with policy and practice guidance in Scotland and discuss any implications which this might have for research on this topic.
Relevant international literature published since 1990 was reviewed and a survey was undertaken of the 32 local authorities, 15 health agencies and 29 other agencies (voluntary and private) who provide a service to this client group (a total of 76 organisations). These organisations were asked to submit for analysis their policy and guidance documents on challenging and inappropriate sexual behaviour.
Definitions
The most common research definition of challenging behaviour refers to behaviour which: places the individual or others in physical danger; results in destruction of their immediate environment; causes at least an hour's disruption; or behaviour which limits or delays access to ordinary community facilities.
There is some confusion in the literature over the precise definition of and distinction between inappropriate sexual behaviour and sexual abuse. The problem in defining the former is identifying what is 'appropriate' sexual behaviour which is likely to differ between different racial, religious and social cultures. The main problem in defining sexual abuse is ascertaining whether it was a consensual act and if the victim was able to provide consent.
The causes or functions of challenging behaviour can be diverse and may include illness, unacceptable environmental conditions or lack of stimulation. An analysis of the function of the behaviour (through examining the antecedents, the behaviour and the consequences) can therefore help to determine the most appropriate intervention.
Inappropriate sexual behaviour may not have a sexual basis but may serve a communicative function or may reflect a lack of knowledge of appropriate behaviour which could be remedied by educational programmes. Again, functional analysis is necessary to help to determine the most appropriate intervention.
However, there is a lack of research into the effectiveness of methods of undertaking functional analysis.
Interventions
Challenging behaviour
The studies reviewed identified three main types of behavioural approaches which have been applied to reduce challenging behaviour. (i) Differential reinforcement is a reward system in which the individual is encouraged to achieve desired outcomes through exhibiting appropriate rather than challenging behaviour. (ii) Teaching functionally equivalent responses involves an analysis of the function of the behaviour and the teaching of more appropriate behaviour which serves the same function. (iii) Gentle teaching aims to reduce challenging behaviour by teaching bonding and interdependence through gentleness, respect and solidarity.
The research evidence in respect of the effectiveness of each of these approaches is inconclusive.
Inappropriate sexual behaviour
Few studies evaluated the effectiveness of interventions to reduce inappropnate sexual behaviour in people with a learning disability and these related mainly to sex offenders with a mild learning disability. The few programmes reviewed used a cognitive behavioural approach in which sex offenders learn to accept responsibility for their behaviour and address the seriousness of the offence and its impact on their victims, by exploring the antecedents and consequences of the offending and the context within which it occurred.
Research has found that a minimum period of probation of 2 years is required to achieve and enforce changes in attitudes of sex offenders with a learning disability and to reduce re-offending. One review of research suggested that cognitive therapy can be used successfully with people with mild learning disabilities if they have some language skills and treatments are simplified.
Education
Education programmes on sexuality and personal relationships for people with learning disabilities is viewed as a means of assisting in the reduction of vulnerability to sexual abuse and of teaching sex offenders what is socially acceptable sexual behaviour (although for the latter, this should be undertaken in conjunction with behavioural interventions).
The literature search identified a few studies which assessed the effectiveness of educational programmes but evaluation methods were found to be inadequate.
The main criticisms of the studies reviewed include a failure to assess skills and behaviour and a failure to conduct follow-up assessments to assess maintenance of increased knowledge and reduction in the level of inappropriate sexual behaviour over time.
Criminal justice responses to offending behaviour
Many alleged offenders who have learning disabilities have been shown to have difficulties in understanding written and verbal information about their rights during police interviews and may require the presence of an appropriate adult. However, the research evidence suggests that police have difficulty in identifying those with a learning disability and that an effective method of identification has not yet been developed.
The research has also shown that police and court interviewing of people with learning disabilities can be very distressing to them and that an awareness of the difficulties which these people have in providing evidence and appropriate interviewing techniques can lead to a higher recall and more reliable evidence.
Staff guidance
Challenging behaviour
There was no response from 11 of the 32 local authorities, 3 of the 15 health and 15 of the 29 other agencies surveyed, concerning availability of documents on challenging behaviour. Of those who responded, less than half of the health agencies (42%) and local authorities (38%), stated that they had policies and guidelines on challenging behaviour, compared to almost all of the 'other' agencies. A total of 20 different documents relating to challenging behaviour were received (5 local authority, 4 health and 11 other agencies).
Documents tended to focus on immediate responses to incidents of violence and aggression rather than on guidance on long-term approaches to reducing challenging behaviour. This may reflect the lack of robust research evidence on the effectiveness of long-term approaches and effective methods of undertaking functional analysis. Only 6 documents provided guidance on conducting this analysis.
Most documents recommended that staff should receive training in responding to violent incidents but only a few suggested that staff should receive training in behavioural programmes.
Inappropriate sexual behaviour
There was no response from 8 of the 32 local authorities, 2 of the 15 health and 10 of the 29 other agencies surveyed, concerning availability of documents on personal and sexual relationships and sexual abuse. Of those who responded, less than half of all organisations had a policy and guidelines on both sexual abuse and on sexuality and personal relationships. A total of 31 different documents were received (9 local authority, 11 health and 11 other agencies).
The main focus of documents was procedures relating to sexual abuse allegations and education on sexuality and personal relationships.
Just over half of all documents failed to provide guidance on interventions for perpetrators of inappropriate sexual behaviour and sexual abuse. Only 6 documents mentioned the need for functional analysis and adopting a behavioural approach.
The survey confirmed research findings that staff training on inappropriate sexual behaviour, abuse and sexuality and personal relationships is frequently ignored by service providers.
Offending behaviour
Only 3 documents relating to offending behaviour of this client group were received and a further 5 organisations intended to develop policies and guidelines in the near future.
Implications for research
The literature review and survey have shown that the available research evidence is insufficient for the needs for service providers when planning services and preparing staff guidelines. Much of the research has been criticised for methodological reasons and there were gaps in the topics covered.
There are a number of areas which require further examination. These include evaluations of the effectiveness of:
  • methods of undertaking functional analysis;
  • behavioural interventions and education programmes which take into account: the different levels of learning disability of clients; different levels of severity and frequency of challenging and inappropriate sexual behaviour; and different service models and service issues (for example, staffing, accommodation and use of specialist services);
  • diversion and other programmes for offenders; and
  • staff training.
The study was carried out by Louise Brown, Consultant. It was funded by the Social Work Services Group of The Scottish Office.
'Challenging and Inappropriate Sexual Behaviour in People with Learning Disabilities: A Literature Review'. The research report summarised in this Research Findings, may be purchased (price £5.00 per copy).
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