The link between physical health conditions and behaviours that challenge

Multimorbidity | Last Updated: 14 Apr 26

Background

Behaviours that challenge, such as aggression, self‑injury, and damage to property, are common among adults with learning disabilities and can have a major impact on quality of life. They can also place considerable strain on families, support staff, and health services. These behaviours are often managed using medication that affects mood or behaviour. However, the underlying causes are not always well understood.

One possible contributor that has received relatively little attention is physical health. People with learning disabilities are more likely to experience physical health problems and difficulties with hearing or sight, and these issues may cause pain, discomfort, or distress that is not easily communicated. We do not yet have a clear picture of how often new physical or sensory health problems are linked to the onset of behaviours that challenge, or which conditions are most strongly associated. This study aimed to address these gaps so that care can be improved and unnecessary medication use reduced.

What we did

We used English GP records to study over 166,000 adults with learning disabilities between 2009 and 2019. We examined whether behaviours that challenge were recorded by clinicians in the year before or after a new diagnosis of common physical health conditions or sensory impairments.

The conditions we studied included constipation, epilepsy, pain, visual and hearing impairment, bowel and urinary incontinence, and sleep problems. We also took account of factors such as age, sex, ethnicity, socioeconomic deprivation, autism, and mental health conditions, to better understand who is at greatest risk and in what circumstances behaviours that challenge are more likely to occur.

What we found

Our findings showed that behaviours that challenge are common and frequently occur alongside new health problems.

· Over one in five adults with learning disabilities had at least one recorded episode of behaviour that challenged during the study period.

· Around 41% of these episodes occurred close in time to a new physical health condition or sensory impairment.

· New diagnoses of all eight conditions studied were associated with an increased risk of behaviours that challenge.

· The strongest associations were seen for bowel incontinence, urinary incontinence, constipation, and sleep problems.

· These links remained even after accounting for demographic factors, autism, and mental health conditions.

What these findings mean

Behaviours that challenge in adults with learning disabilities may often be a response to physical discomfort, pain, or unmet health needs. This highlights the importance of routine health checks and careful physical assessment when new or worsening behaviours are observed.

Our findings support existing clinical guidance that recommends ruling out physical health problems before focusing on behavioural or psychological interventions. By improving the recognition and treatment of physical health conditions in people with learning disabilities, it may be possible to reduce the frequency and severity of behaviours that challenge and improve overall wellbeing.

Group member(s) involved in this research

25 035 Scottish Learning Disability Staff Portraits Elliot Millington 003 staff image

Dr Elliot Millington

Elliot is a Research Associate with the Scottish Learning Disabilities Observatory. He recently completed his PhD with the School of Psychology and Neuroscience, also at the University of Glasgow. His thesis explores the links between sensory processing and anxiety in autistic adults. Elliot has a quantitative focus and will be finding insights in large administrative datasets which can reduce the health inequalities experienced by people with learning disabilities.

Professor Craig Melville

Craig is a Professor of Neurodevelopmental Psychiatry in the School of Health and Wellbeing at the University of Glasgow. His work focuses on using evidence from research to inform the development of interventions and policy to improve the health of people with neurodevelopmental conditions. Craig has worked on clinical trials of complex interventions, such as psychological therapies, weight management and health checks in primary care. Evidence from epidemiological research has been central to the development of these clinical trials and his work with SLDO centres on how to use Scotland’s national datasets to understand and tackle the health inequalities experienced by people with neurodevelopmental conditions.

Professor Andrew Jahoda

Andrew Jahoda is a Professor of Learning Disabilities in the School of Health and Wellbeing at the University of Glasgow. He also has an honorary position as a consultant clinical psychologist with NHS Greater Glasgow and Clyde. Andrew has worked at Glasgow University since 1998. His research interests concern the mental health and wellbeing of people with learning disabilities. This includes work about the impact of stigma and ways of promoting inclusion. Another strand of research is about adapting psychological therapies like Cognitive Behavioural Therapy and behavioural activation for people with learning disabilities, to make them more accessible and sensitive to people’s lived experience.

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Dr Anne MacDonald

Anne is the Lead for Learning, Teaching and Scholarship for the Observatory. She is a Senior Lecturer in the School of Health and Wellbeing at the University of Glasgow. In this role she leads on developing and delivering postgraduate qualifications in Positive Behaviour Support for the health and social care workforce, with a focus on people with learning disabilities and behaviours that challenge. Prior to this, Anne worked for nearly 20 years with a third sector social care provider where she managed the organisation’s Positive Behaviour Support team. Anne also works part-time as a Professional Advisor for Complex Needs in the learning disability policy team at the Scottish Government. As part of this role, she wrote the Scottish Government’s Coming Home report which focused on out-of-area placements and delayed discharge from hospital for people with learning disabilities and complex needs. Anne is Senior Editor for the International Journal of Positive Behavioural Support. She also chairs the steering group for the Positive Behaviour Support Community of Practice for Scotland.

Dr Amanda Gillooly

Amanda is a Research Associate at the University of Glasgow. She is interested in research promoting the mental health and wellbeing of people with learning disabilities and their families. Since joining the School of Health and Wellbeing in 2019, Amanda has worked on clinical trials focused on adapting and evaluating psychological therapies for people with learning disabilities. Prior to working at the University of Glasgow, she completed a PhD at the University of Strathclyde, examining the social experiences of children and young people with Williams syndrome. Amanda also previously worked as a Research Associate at the University of Edinburgh, working across studies with children with learning disabilities and their families.

Christine Pacitti

Christine is a doctoral student with research interests in health inequality, inclusive research, and optimising health care and prescribing for adults with learning disabilities. Her PhD research is examining the treatment of pain and painful conditions experienced by adults with learning disabilities focusing on any health inequality that may emerge from this project. Christine is a clinical pharmacist, with expertise in mental health, and has practiced professionally within community, hospital and mental health settings. Prior to commencing her doctoral studies, Christine worked within NHS learning disability psychiatry multi-disciplinary teams providing support with medication for people with learning disability and complex health needs. Christine is an experienced carer of a family member with learning disability and complex health needs.