Treatment interventions forpeople with aggressive behaviourand intellectual disability
The term ‘aggression’ is used widely and loosely to refer to any or all of thefollowing acts: physical assaults on peers, staff or family members, of variousintensity; verbal threats and hostile statements; threatening gestures; tantrums;and property destruction. Further confusion comes from the use of a varietyof terms other than ‘aggression’ to refer to more or less the same forms ofbehaviour (e.g. ‘violence’, ‘extreme negativism’, ‘oppositional and assaultivebehaviours’). At times, still other terms are used that refer to unobservableinternal states (e.g. ‘angry’, ‘vengeful’, ‘overstimulated’ and ‘poor impulsecontrol’).
There is no psychiatric diagnosis of ‘aggressive behaviour disorder’. Rather,
aggressive behaviour may be a symptom of a number of DSM–IV psychiatricdiagnoses, including conduct disorder, oppositional defiant disorder, behaviourdisorder not otherwise specified, intermittent explosive disorder, impulsecontrol disorder not otherwise specified and some personality disorders. Thus,aggressive behaviour may be related to a very wide range of diagnoses. Severalstudies of large databases from California and New York have indicated norelationship between aggression and any specific psychiatric disorder in peoplewith intellectual disability.
IS AGGRESSION COMMON IN PEOPLE WITH AUTISM ANDINTELLECTUAL DISABILITY?
The research literature shows that the prevalence of aggression among peoplewith intellectual disability and autism ranges from 9% to 31%. The medianreported is about 20%. Higher rates of aggression are found in institutionalsettings – up to 45% in some studies. However, many schools, families andcommunity residential and vocational settings now have a significant minorityof clients with aggressive behaviour. Are particular groups at risk of developing aggression?
Aggression is more likely in persons with one or more of the following con-ditions:
• greater degrees of intellectual disability; • organic aetiology; • organic brain damage, and, perhaps especially, temporal lobe epilepsy; • sensory disabilities; • difficulties in language; • poor coping skills; • poor problem-solving skills; • poor social skills; • poor social support; • concomitant psychiatric disorders.
Some studies have found that more males than females exhibit aggression. Further, aggressive behaviour is exhibited more frequently or more intenselyin adolescents and young adults. It usually declines in middle and later adult-hood. However, aggressive behaviour is often very stable over time. Thus,many families have to cope with aggression for many years, often with little orno support from professional staff.
Aggression may be modestly associated with certain causes of intellectual
disability. Research into behavioural phenotypes has suggested that certaingenetic syndromes, such as Down’s syndrome and fragile X syndrome, may beassociated with lower rates of aggression than other forms of intellectual disability.
WHAT ARE THE RISKS OF SHOWING AGGRESSIVEBEHAVIOUR?
To the self
Aggressive behaviour has many serious consequences for both clients andpeople around them. The client is often socially rejected and stigmatised. Further, those who are aggressive often are the victims of retaliation frompeers. They are also at risk of abuse from staff and family members. Further,the client may also lose opportunities for integrated community activities,integrated education and living settings. Informal management practices fromfamily members as well as staff, who are reluctant to include them in activitieswith others, may also restrict clients’ lives.
When people with chronic aggression fail to respond to simple interventions
they often receive multiple interventions. Many of these interventions are bothrestrictive and ineffective. Under the guise of behavioural interventions, clientsmay lose access to their personal possessions, work, money, community activi-ties and access to their family and friends. Additionally, many people withchronic aggression are prescribed multiple psychotropic medications, whichplaces them at risk of side-effects and drug interactions. Aggression is a majorrisk factor for failure of family and community placements and for admissionsand multiple admissions to institutions and psychiatric facilities. To others
Aggressive behaviour also represents a significant risk for others around theperson. Injuries to peers, staff and family members are not uncommon. Theseinjuries can lead to significant costs to service providers in the form of lost staffdays and compensation and work-related disability claims. Additional costs canalso arise from the need to provide enhanced staffing, additional staff training,specialised treatment facilities, and community behavioural support teams.
HOW DO WE CHANGE AGGRESSIVE BEHAVIOUR BYUSING BEHAVIOURAL STRATEGIES?
No single biological or environmental cause of aggressive behaviour in peoplewith autism or intellectual disability has been identified. Many developmentalpathways contribute to the current form of a particular person’s aggression. Further, the current factors maintaining aggression may change over time. For example, inadvertently ignoring adaptive communicative responses and
differentially responding to progressively more intrusive requests may initiallyshape aggression. Later, this same topography may come to elicit help duringperiods of illness.
It is important to note that aggression often occurs with other challenging
behaviours, such as non-compliance, tantrums and self-injury. Applied behaviour analysis
Applied behaviour analysis (ABA) is the natural science of observable behaviour. It focuses on observable behaviour that is public and measurable. Observablebehaviour has several dimensions, such as frequency, duration, latency, inten-sity and sequencing. Interventions are based on learning principles and anunderstanding of the idiosyncratic environmental events maintaining eachperson’s behaviour.
The most important element of ABA is enhancing the client’s quality of life
and social acceptance, by teaching behaviours that are valued by the clientand significant others around them, and which are also functional in replacingthe client’s aggression. Thus, ABA emphasises teaching social skills, languageskills, educational and vocational skills, and coping strategies, such as relax-ation training, problem solving and anger management. Interventions that donot include these elements do not include an essential element of ABA.
ABA also emphasises the current environmental events. The history and
development of the problem are typically underplayed and contribute relativelylittle to the understanding of aggression and in guiding treatment. We mayspeculate on how a particular behaviour was shaped or how a traumatic eventmight relate to classical conditioning. However, such hypotheses are little morethan speculation and not subject to verification.
Interventions based on ABA are described in a precise and technological
manner. Thus, with adequate experimental design, one can be convincedthat changes in the observed target behaviour are related to changes in theenvironment. This approach also allows for replication by other cliniciansand researchers. Intervention is carried out not in the laboratory or by anexperimenter but in the real world, where the person lives and works, and bythe people who are typically present. Thus, staff and parent training, super-vision, and the motivation of change agents are key elements of anybehavioural intervention. Finally, intervention is evaluated with observabledata on increases in adaptive behaviours and decreases in the target behaviour. This contrasts with most other approaches that monitor and evaluate inter-ventions by self-reports, global impressions by third parties, or even nosystematic monitoring of intervention effects at all.
Two common learning mechanisms are classical (respondent) and operant
conditioning. Classical conditioning begins with an unconditioned response,such as salivating in the presence of food, or blinking when there is an objectin the eye. When a neutral stimulus, such as a clicking noise, is repeatedlypaired with an unconditioned stimulus, such as a blast of air, the neutralstimulus (now the conditioned stimulus) eventually comes to elicit the con-ditioned response in the absence of the unconditioned stimulus. Thus, theclick eventually elicits blinking. Many examples of classical conditioning areassociated with survival functions such as eating, drinking and avoidance ofdanger. Its antecedents control classically conditioned behaviour. Examples ofinterventions based on antecedent control include systematic desensitisationand some forms of anger management. For example, suppose social criticism isan antecedent that elicits aggression towards another person. A client mightbe taught relaxation training and be gradually exposed to progressively moreprovocative forms of criticism paired with relaxation training. This interven-tion is based on changing the relationship between antecedents (socialcriticism) and behaviour (aggression).
In contrast, operant behaviour is controlled by its consequences. In operant
learning, the consequences of behaviour – reinforcers and punishers – deter-mine the future probability of behaviour. Operant learning is probably moreimportant than classical conditioning. Operant learning using techniques suchas shaping has been used to teach many important social and language skills. Shaping is sometimes described as ‘successive approximations’, because, overtime, closer and closer approximations to the final response being taught arereinforced. For example, presenting an item the client likes can shape appro-priate requesting. Initially any communicative response, such as pointing,might be reinforced with access to the item. All other responses would beplaced on extinction, since they would not be followed by access to the itemor any other reinforcer. Later, some verbal response might be required. Laterstill, the sound ‘p’ might be required to request popcorn, and so on, until theclient can request popcorn by saying the entire word.
Much important challenging behaviour is probably inadvertently learned
through shaping. It is easy to imagine how, over time, a quiet request is ignoredand eventually extinguished. A quiet verbal threat is then inadvertently shapedinto a loud verbal threat, accompanied by a gestural threat. Later, as thesebehaviours are also placed on extinction, staff and parent avoid the client andrespond only to physical aggression. As socially appropriate behaviour, such asrequesting, is ineffective in gaining the desired consequence, progressivelymore intense forms of aggression are inadvertently shaped. Eventually aggres-sion becomes the only functional behaviour. Research on animal models has
shown that unusual, pathological and even lethal behaviours can be learnedthrough shaping quite quickly.
Aggression may be shaped and maintained by either access to attention or
tangible items (e.g. drink, food), or access to preferred activities (e.g. ritualisticbehaviours). Aggression can also be shaped and maintained by avoidance ofnegative consequences. The most common maintaining consequences here areescape from work, a task or academic demands. In some cases, especially insome people with autism, escape from excessive stimulation, noise, crowding,demands or merely interacting with others may maintain aggression. Recentresearch on ABA and aggression has focused on operant conditioning as amodel for aggression in persons with intellectual disability and autism.
If operant aggression is maintained by its consequences, then teaching a
more appropriate way to request those consequences may introduce a com-peting response, and reduce the frequency of aggressive behaviour. Thus,aggressive behaviour can be thought of as a way of requesting. This form ofintervention has become known as ‘functional communication training’. Thus,if a client’s aggression is reinforced by escape from work, then teaching theclient to request a break may be an effective way to reduce aggression. Thiswould be especially so if staff respond promptly to appropriate requesting. Functional assessment
ABA can be contrasted with much technique-driven behaviour modificationof the past. These technique-driven behavioural procedures, such as time out,token economies and schedules of reinforcement, were implemented withoutan understanding of the behaviour that was being changed. Further, treatmentswere often implemented based on the therapist’s preference and local practice,rather than an understanding of each client’s motivation for aggression.
The current standard of practice is to ascertain, before intervention, the
individual client’s motivation for aggression. This information is then used todevelop an individually tailored intervention. Therefore, such an interventioncan identify and strengthen adaptive behaviours that serve the same functionas the target behaviour. For example, if aggression is motivated by attention,the person can be taught appropriate social skills, such as hand shaking, raisingan arm, or learning to say ‘hey, come here’, to gain attention in an acceptablemanner. Interventions can also include rescheduling the reinforcer that main-tains aggression, such as rescheduling attention at times when no aggressionoccurs as well as ensuring that no attention is given after aggression occurs.
Interventions based upon a functional assessment can also include removing
those events that trigger aggression. For example, if attention-maintained
aggression is more likely to occur after the person has been ignored for anextensive period of time, one such intervention to reduce attention-maintainedaggression would be to give frequent periods of attention. This would ensurethat the person is not deprived of attention. Thus, the purpose of a functionalassessment is to develop an individually designed intervention, based on theindividual functions of each person’s aggression.
Pre-intervention assessment can take various forms. Interviews with the
client, family members and staff are very often used. These interviews cansometimes be useful for developing a broad-brush picture of the problem andcan be used to develop a number of competing hypotheses about the targetbehaviour. However, the use of interviews as the only basis for a functionalassessment is not recommended. The information gleaned from interviews isoften incomplete and inaccurate. Other assessment methods are needed todevelop an accurate functional assessment.
Some authors have developed questionnaire methods to identify the functions
of challenging behaviours. Matson’s Questions About Behaviour Function isone example of this approach (Matson et al, 1999). Informal, direct observationof the behaviour in the natural environment can often give clues as to thenaturally occurring triggers and consequences of aggression. Staff records ofincidents can be analysed for patterns of when, where and with whom aggres-sion occurs. Sometimes direct manipulation of the environment can be usedexperimentally to manipulate the behaviour. In this way the clinician canbe more confident that a functional relationship between aggression and theenvironment exists. Surveys have shown that practitioners tend to use inter-views, questionnaires and direct observation but not experimental methods todetermine the function of challenging behaviours such as aggression. Staff and parent training
Since aggression is mediated by the behaviour of other people, behaviouralinterventions require that the people around the client change their behaviour. Unfortunately, part of the challenge is that the client has enormously powerfulconsequences for these people. The client’s behaviour may powerfully shapecounter-habilitative practices in staff, such as not placing demands on theclient wherever possible.
There has been extensive research on staff and parent training. Generally,
verbal training, reading and courses alone may lead to improvements in knowl-edge. However, such an approach does not lead to improvements in skills orimplementation of recommended interventions. To change staff and parentbehaviour, direct training using brief instruction, modelling, rehearsal to mastery
criterion and feedback may lead to the initial acquisition of the skills. Afterinitial training, considerable effort is needed to ensure maintenance of staff andparent behaviour. The most effective format for this is through direct obser-vation of implementation, feedback on performance and periodic retraining. Intensive early behavioural intervention
Over the past 15 years, Lovaas’ work on intensive early intervention withchildren with autism has raised considerable interest (see Lovaas et al, 1989). The possibility that 47% of children who were diagnosed with autism duringinfancy or early childhood could gain apparently normal functioning andmaintain this into adolescence is intriguing to researchers and has attractedconsiderable interest from parents. However, the impact on aggression has notbeen directly reported. Nevertheless, the finding in Lovaas’ early studies thatnearly half of the children were mainstreamed and apparently indistinguishablefrom non-disabled peers suggests that aggression was not a significant problem,at least for these children. This raises the possibility that early intensive behav-ioural intervention may prevent later aggression in children with autism. Restraint
Recently the use and risks of restraint have received much attention. Restraintmethods have been associated with a significant number of client deaths inthe United States. Some behavioural interventions have incorporated restraintas a consequence for aggression. Indeed, there is good evidence that contin-gent restraint may be an effective intervention to reduce aggression in somepeople. However, the current climate strongly favours the use of restraint onlyin emergencies in which there is imminent danger of harm to self or others. Services that use restraint to treat aggression should focus their energies onrestraint reduction. They should be prepared to justify the use of restraint inany other circumstances.
HOW DO WE CHANGE AGGRESSIVE BEHAVIOURBY USING PHARMACOTHERAPY?
The use of psychotropic medication with people with developmental disabil-ities remains for many a controversial issue that is full of contradictions. Onthe one hand, we eschew the use of medications, turning to them as a last
resort. On the other, staff and family members often clamour for medicationsat the first sign of aggression before making any rational consideration of thealternatives. Perhaps one-third of clients living in group homes now takepsychotropic medication. Medical professionals point to diagnosis as the basisfor the use of medication. However, surveys of American physicians takenduring the development of DSM–IV revealed that many practitioners willinglyadmitted that they rarely adhere to DSM diagnostic criteria. Some psychiatristsregard diagnosis more as an administrative issue related to billing, rather thana clinical issue used as the basis for the use of medication. Professionals vacillateover whether we can use polypharmacy rationally. In spite of this oft-voicedconcern, we often observe consumers on five or six psychotropic medicationswith an accompanying list of multiple diagnoses.
Another important recent issue is the limited amount of good-quality research
on the evaluation of psychotropic medication with people with intellectualdisability or autism. This is a relatively small market for medication comparedwith, say, antidepressants for use within the general adult population. Thus,drug companies generally have little interest in funding research for this relativelysmall population. Many reviews of psychotropic medication repeatedly mournthe absence of basic features of experimental design, such as adequate descrip-tion of participants, control groups, meaningful outcome measures, blindingprocedures, social validity data, follow-up data and data on adaptive behaviour.
An often-repeated recommendation has been to base the use of psychotropic
medication on an accurate psychiatric diagnosis. Recently, some progress hasbeen made here. In at least some cases it is possible to make a true ICD or DSMdiagnosis for people with borderline to moderate intellectual disability. Further,it is possible to modify the criteria to make them more concrete. Interviewing aclient with intellectual disability may have to be done more carefully than witha person of average intelligence, but it is certainly possible to do so. Structuredpsychiatric interviews, such as the Psychiatric Assessment Schedule for Adultswith Developmental Disability (PAS-ADD; Moss, 1999), have shown promisein this regard. Additionally, screening instruments such as the mini-PAS-ADD(Moss, 1999) and the Diagnostic Assessment for the Severely Handicapped(DASH; Matson et al, 1996) have also shown promise.
In persons with severe or profound intellectual disability, the diagnostic
challenges are more marked. These clients are usually minimally verbal ornon-verbal. They do not directly complain of their own distress or requestservices. Therefore, diagnosticians are dependent upon reports from direct-care staff, other professionals and family members. Making inferences abouteach other’s mental state is difficult for most of us. The evaluation of themental state of a person with a severe disability is a highly inferential process.
However, where there are publicly observable phenomena that correspond todiagnostic criteria – for example, weight loss – these phenomena may some-times be reliable and may assist in diagnosis. The issue of whether challengingbehaviours, such as aggression, can be interpreted as a behavioural equivalentof an underlying psychiatric disorder in a person with severe or profoundintellectual disabilities remains controversial.
No single psychotropic medication is specifically effective for aggression.
The best sources of information in this area that practitioners can availthemselves of are publications from the International Consensus Panel onpsychotropic medication in persons with intellectual disability (see Reiss &Aman, 1999). Below is a summary of research related to psychotropic medic-ations and aggression in people with intellectual disability. Neuroleptic medications
There have been a few studies of the use of chlorpromazine and haloperidolfor aggression. These indicate that decreases in aggression in children withhyperactivity or conduct disorders may occur. Of three studies that have usedsound methods, one showed an increase, one a decrease and one no effect onaggression.
Unfortunately, neuroleptics have significant side-effects, including sedation,
tardive dyskinesia and neuroleptic malignant syndrome, which may be fatal. Some studies have reported that as many as a third of children with autismtaking neuroleptics experience drug-related dyskinesia. Neuroleptic medicationcan also have serious cardiac side-effects. They may also impair learning. Because of their serious negative side-effects many practitioners are movingaway from the use of neuroleptics, to other classes of psychotropic medication. Anticonvulsants
Some antiseizure medications, such as carbamazapine and valproate, aresometimes used as mood stabilisers in persons with aggression. Under clinicalindications there is no discussion of these medications and aggression. More-over, there have been no methodologically adequate studies of aggression inthis population. Antidepressant drugs
There have been a handful of methodologically adequate studies of a varietyof antidepressants for aggression. Several reported a large reduction in
aggression. One reported an insignificant reduction in aggression and anotherreported a significant increase in aggression. Anxiolytic and sedative medication
Benzodiazepines have been shown to be effective in reducing anxiety inpersons with intellectual disability and autism. It is therefore possible that,when aggression is mediated by anxiety or when aggression functions to reduceanxiety, benzodiazepines may be appropriate. However, it is important tobalance the benefits against the potential problems of sedation and toleranceto benzodiazepines.
There is little support for the use of antihistamines to manage acting-out or
hyperactive behaviour. There has been one controlled study of buspirone. Thisstudy found reductions in aggression and self-injury, but not anxiety, in five outof six cases. Reductions ranged from 26% to 63% of baseline rates of aggres-sion. In one uncontrolled study, similar results were found. Some authors haveconcluded that the use of buspirone for aggression appears to be promising. However, this tentative conclusion is based on relatively few studies with thispopulation. Mood stabilisers
There have been three double-blind trials as well as several case series toevaluate lithium for aggression. They have produced equivocal results. Stimulants
There have been several studies of methylphenidate in this population. Itseffects appear to be limited to the symptoms of attention deficit hyperactivitydisorder but not aggression. Clonidine
This is used primarily as an antihypertensive agent. There has been littleresearch specifically on aggression.Beta-blockers
There have been no controlled studies on aggression in people with intellectualdisability. Opiate blockers
Naloxone is primarily used for self-injurious behaviour. However, there is nopublished information on aggression. Fenfluramine
There is some evidence that fenfluramine may reduce hyperactivity in autism. However, there is little evidence that it has an impact on any other symptoms,including aggression. Fenfluramine has recently been withdrawn from the marketbecause of serious negative cardiac side-effects. Atypical neuroleptics
In recent years, so-called ‘atypical’ neuroleptic medications have been placedon the market. These include clozapine, risperidone, olanzapine and quetiapine. These agents were originally evaluated in patients with refractory schizo-phrenia and other psychoses but without intellectual disability. They wereshown to be superior to traditional neuroleptic medications – at least whencompared with higher doses of them – in the alleviation of the negativesymptoms of schizophrenia as well as effective in treating the positive anddisorganised symptoms. At this time it appears that these new agents are notso commonly associated with some of the more serious side-effects of neuro-leptics, especially tardive dyskinesia and sedation.
In recent years, the use of atypical agents in persons with autism and intel-
lectual disability has greatly expanded. As with people of average intelligence,they have an important role in the treatment of psychoses. However, in ser-vices for people with intellectual disability and autism, they have been usedfor a wide range of psychiatric disorders and challenging behaviours, includingaggression. As well as a number of descriptive and uncontrolled case studiesand open-label trials, there have now been two double-blind, cross-over,placebo-controlled trials of their use for a variety of challenging behaviours,including some clients with aggression. This research suggests that atypicalneuroleptics may be effective in some clients with aggression. However, themechanism of action is uncertain, as negative side-effects, such as sedationand significant weight gain, may also account for behaviour change.
Future research could address how to match diagnostic indicators or other
predictors of a positive response to atypical antipsychotic agents. However, astime goes on, more negative side-effects of these medications are also beingreported. Secretin
Over the past few years secretin, a gut hormone, has received considerableattention from parents and practitioners. Anecdotal reports had been madethat intravenous infusions of secretin may lead to global improvement in somechildren with autism and pervasive developmental disorders. Unfortunately,the first two published double-blind placebo-controlled trials revealed thatthere were no differences between secretin and placebo. Nonetheless, theseresults have not deterred those who believe in secretin’s effectiveness in personswith autism.
The overall research evidence for the use of psychotropic medication based onthese studies is poor to equivocal. This is due to both the small quantity andthe overall poor quality of research. The new atypical neuroleptics, such asrisperidone, may be effective for some people, but there is insufficient researchto be conclusive. One way forward is to assume that aggression is multi-deter-mined. Some forms may be purely learned and have no biological basis. Othersmay be very closely related to a concomitant psychiatric diagnosis. Still otherforms may have a complex or indirect relationship to a psychiatric diagnosis. Itis unreasonable to expect one intervention or drug to be particularly effectivein reducing aggression. Research is needed to evaluate whether a differentialpsychiatric diagnosis can be made in cases of aggression and whether it canpredict a differential response to different classes of psychotropic medication. Moreover, research needs to help us identify predictors of who responds towhich medication.
Clinicians can improve their prescribing practice by using data-based decision
making, having clearly defined symptoms to track the response to psychotropicmedication, and having explicit, written diagnostic hypotheses as to therelationship between a possible psychiatric disorder and aggression.
There are many therapies for aggression other than those based on ABA andpharmacological therapies. Very few have been evaluated and they all shouldbe regarded cautiously. Some have been evaluated and the results of the evalu-ations have been negative.
The advent of the Internet has led to a very rapid transmission of
information among professionals and parent groups. This has led to the rapid
dissemination and demand for fads and unproven therapies. This is equallytrue for both biological and socially based interventions. • Counselling is often practised with persons with borderline, mild and
moderate intellectual disability. To the extent that counselling includesvarious behavioural methods such as relaxation training, problem-solvingand anger-management skills, it is possible that counselling may be effec-tive. However, there is no evidence that either non-directive or supportivecounselling methods are effective in treating aggression with this popu-lation. Counselling methods are almost always contraindicated with personswith moderate through to profound intellectual disability. • Psychotherapy. There is a surprisingly long history of psychotherapy with
personswith intellectual disability and autism, including various forms ofnon-verbal psychotherapy. After more than 50 years of practice andresearch into psychotherapy, there is very little evidence that it is an effec-tive treatment for aggression in persons with either autism or intellectualdisability. • Cognitive therapies Some authors have suggested that cognitive therapy might
be appropriate for some persons with either intellectual disability or autism. In cognitive therapy the therapist hopes to improve behaviour by changingthe client’s beliefs and perceptions of the world. This is a possibility, but todate there is little evidence to support this. • Sensori-integration therapies. Sensori-integration therapy (SIT) is based on
the hypothesis that challenging behaviours, such as aggression, are due tolack of adequate sensory stimulation in persons with intellectual disabilities. Recently, a meta-analysis of SIT studies was published that found littleevidence of its effectiveness. Indeed, there is evidence that in some casesSIT may increase challenging behaviours. Thus, SIT has been evaluatedrelatively well, but the results indicate that it is not effective.
A wide range of other therapies are used for the treatment of autism andaggressive behaviour. All of these therapies have their passionate advocatesand endorsing parents. These therapies include: aromatherapy; music therapy;interventions based on theory of mind; re-parenting; the development, individ-ual difference, relationship (DIR) model, also known as floor time; touchtherapy; holding therapy; facilitated communication therapy; auditory integ-ration therapy; adrenocorticotrophic hormone; immunological therapies, suchas immune globin; oral antifungals; special antifungal diets; vitamin therapies;dietary therapies, such as gluten-free diets and the Feingold diet; dolphintherapy; therapies for putative allergies to food additives and other toxins; and
so on. (I have recently heard of an extract of cow placenta being used withchildren with autism.) By the time this chapter is published the list will un-doubtedly be longer. At this time there is little evidence to support the use ofthese therapies to treat aggression. Indeed, some of these therapies have poten-tially serious side-effects, which, given the unproven status of the therapies,may lead one to judge that these negative side-effects would cause rationalphysicians to reject their use. At the very least, use of these therapies distractspeople from those interventions that are more likely to help the client. As wemove closer and closer to evidence-based practice, there continues to be agreater need for advocates and practitioners to demonstrate the effectivenessof these and other therapies.
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BASD Strategy Meeting Paris, 9-10 October, 2001 THE GLOBALISATION IMPERATIVE Reuel Khoza On behalf of Eskom and the Business Co-ordinating Forum of South Africa, I wish to thank, the BASD Steering Committee Chair, Mark Moody Stuart for hosting this meeting. United Nations Secretary-General, Kofi Annan has stated that “We have to choose between a global market driven only by calculation