الفهرس 
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Abstract
Challenging behavior in individuals with intellectual disability is a complex but common problem that can present diagnostic and management challenges for healthcare professionals. All behavior serves a purpose, has an origin and meaning, and is therefore produced by an interaction between an individual and their environment.
Challenging behavior is common in intellectual disability, but it is difficult to diagnose and manage. It can adversely affect the quality of life of the individual and cause the breakdown of community placements, resulting in hospital admission.
Psychological factors include psychological trauma, mental illness and neuropsychiatric disorders such as autism. Social factors may include family discord and economic deprivation, negative life events, bereavement and communication difficulties. Individuals often use challenging behavior as a form of communication when they would like to gain access to a particular object or activity or avoid or escape an activity or person. It may also serve to communicate dissatisfaction with their environment or lack of support due to poorly trained staff or inadequately resourced day services.
Managing behavioral problems is a major concern in the comprehensive rehabilitation of people with ID. Children with ID that attend schools receive some form of behavioral management, irrespective of the nature of school (special or regular). In rural India, where most children with ID do not attend school, there is no institutional support in place to help children with their behavioral problems. In addition, the outreach activities performed by rehabilitation institutions in rural communities are poor. Insufficient awareness, misinformation, malpractice, and social issues negatively affect the management of behavioral problems in children with ID in rural communities. In the absence of institutional support, parents apply various methods of handling such behavioral problems.
There is an unmet need for studies that focus on behavioral interventions for children with ID that live in low- and middle-income countries. For example, we do not yet know which ID benefit more from behavioral intervention or if there is any relationship between a child’s intelligence quotient (IQ) (a child who has ID) and their behavioral improvement after an intervention.
The main aim of this study was to study the outcome of behavioral intervention in children who challenge intellectual disability as these studies are scarce in Egypt.
This prospective study was conducted at Sohag governorate. The study included 150 children with mild and moderate intellectual disability of both sexes. The duration of the study ranged from 6-12 months.
The main findings of the study revealed that:
Among our studied children with ID, their age ranged between 2-10 years with mean value of 4.90 ± 1.80; 51.3% of them were ≥5years. They were 66% male and 34% female, 33.5% has history of consanguinity. Most of them 64% were born via NVD.
16% has prenatal risk factors (old maternal age in 7.3%, maternal infection in 4.7% and hypertension in 4%. While 25.3% has post-natal risk factors; 23.3% of them were admitted to NICU.
among our studied children with ID, most of them have delayed language development. Speech was started at age 2 years in 36% of children and at age 1.5 years in 24.7% of children. Furthermore, 86% of them have motor developmental delay.
all of them need speech & skills sessions that ranged between 40 – 80 sessions with mean value of 53.24 ± 9.20. Only 18.7% of them need physiotherapy intervention. Physiotherapy session ranged between 20 – 43 sessions with mean value of 29.39 ± 9.63.
the commonest underlying etiology for ID was autism in 12%, followed by Down syndrome in 10.7%, delayed developmental milestone in 6%, then motor disability in 5.3%, hearing impairment in 4.7%, hyperactive/inattentive in 3.3% and lastly metabolic disease in 1.3% while no abnormalities were detected in 56.7% of the studied children.
The current study showed that 6 months after behavioral interventions, Stanford Binet intelligence scale scores show statistically significant increased than before behavioral interventions in children with ID. 6 months after behavioral interventions, Vineland Adaptive Behavior Scale scores show statistically significant increase in overall adaptive scale, communication, daily living skills and socialization scores than before behavioral interventions in children with ID.
Children who did not need NICU admission have statistically significant higher overall adaptive scale score difference and statistically significant lower daily living skills and socialization score difference than children who did not need NICU admission.
Children with delayed motor development have statistically significant lower verbal score difference and statistically significant higher communication and motor skills score difference than children with normal motor development.
there is statistically significant negative correlation between nonverbal, fluid reasoning, quantitate reasoning, visio-spatial orientation scores and age. Also, there is statistically significant negative correlation between quantitate reasoning scores and the amount of skills session. While there is statistically significant positive correlation between all Stanford Binet scale scores and the number of physiotherapy session. Score difference of overall IQ scale, quantitate reasoning, visio-spatial orientation scores have statistically significant positive correlation with age. While score difference of quantitate reasoning scores have statistically significant negative correlation with the amount of skills session. Also score difference of nonverbal, knowledge, visio-spatial orientation scores have statistically significant negative correlation with the number of physiotherapy session.
There is statistically significant negative correlation between daily living skills, motor skills, maladaptive behavior scores and age. While there is statistically significant positive correlation between the socialization score and the amount of skills session. Score difference of communication, daily living skills, socialization scores have statistically significant positive correlation with age. While score difference of maladaptive Behavior have statistically significant negative correlation with the amount of skills session. Also score difference of communication scores have statistically significant negative correlation with the number of physiotherapy session.
Based on our findings, we recommend for further studies on larger sample size and on large geographical scale to emphasize our conclusion.
CONCLUSION
This prospective study was conducted at Sohag governorate. The study included 150 children with mild and moderate intellectual disability of both sexes. The duration of the study ranged from 6-12 months.
Children with ID have needs which present early in life and early intervention may prevent or ameliorate later deficits. Unfortunately, there has not been a significant amount of robust research on behavioral interventions for addressing the needs of young children with ID. Much of the research on focused behavioral interventions targets challenging behavior, rather than skill building. Evaluations of comprehensive behavioral interventions have not emphasized children with ID and there is a need to illustrate the utility of interventions established among individuals with ID.
There is very little support for use of pharmacological treatments for people with challenging behavior and intellectual disability in the absence of coexisting mental illness. However, medication may be required in the presence of high arousal and severe aggressive behavior. There is emerging interest in behavioral interventions for reducing challenging behavior, including positive behavioral support, a values-led approach that is person centered.
The literature reviewed suggests that behavioral interventions demonstrate promise for use with young children who challenge intellectual disability. However, there is still a paucity of research in this area.
The outcome of this behavioral management study suggests that behavioral intervention can be effectively provided to children with ID.
RECOMMENDATIONS
The caliber of the research needs to be improved in several respects
Research recommendations:
Further studies on larger sample size and on large geographical scale to emphasize our conclusion, Given the likely importance of parent factors influencing outcomes, having parent choice be the method of group allocation is problematic.
Functional analysis and function-based treatments based on the principles of applied behavior analysis are considered best practices.
Pediatricians play a crucial role in early identification of problem behavior, referral to early intervention services, and parent education.
Research emphasis should continue to include the development of appropriate behaviors as researchers evaluate the effects of positive behavioral interventions on challenging behaviors. However, future research needs to concentrate on examining specific components of interventions that are responsible for behavior change, as well be explicit in linking the interventions to functions.
Clinical recommendations:
The increasing proliferation of treatment approaches for challenging behavior and the ongoing improvement in study design, including randomized controlled trials, are cause for optimism regarding the enhancement of evidence-based care for individuals with intellectual and developmental disabilities and challenging behavior.
The participants need to be described fully both diagnostically and developmentally and should be assessed with standardized instruments.
Specification of the nature and quality of the intervention needs to be done more precisely. Odom et al. (2010) found, in an evaluation of 30 comprehensive treatment programs, only about a third of them operationalized procedures or curricula well enough to be replicated. Fidelity of implementation is also essential to be documented, which very few studies provide.
More research is needed on predictors/correlates of outcome, to help account for the tremendous heterogeneity among children’s outcomes. Existing research has focused on child characteristics such as age and IQ but there is a need for studies examining treatment quality-related factors as well as family-related factors and perhaps, the interactions of these factors with each other and with child characteristics.
It would be beneficial to compare different specific models in relatively large, diverse samples, with a view to perhaps determining whether certain approaches are more effective for certain types of children and families.