A complex systems perspective on chronic aggression and self-injury: case study of a woman with mild intellectual disability and borderline personality disorder.

BACKGROUND: Challenging behaviors like aggression and self-injury are dangerous for clients and staff in residential care. These behaviors are not well understood and therefore often labeled as "complex". Yet it remains vague what this supposed complexity entails at the individual level. This case-study used a three-step mixed-methods analytical strategy, inspired by complex systems theory. First, we construed a holistic summary of relevant factors in her daily life. Second, we described her challenging behavioral trajectory by identifying stable phases. Third, instability and extraordinary events in her environment were evaluated as potential change-inducing mechanisms between different phases. CASE PRESENTATION: A woman, living at a residential facility, diagnosed with mild intellectual disability and borderline personality disorder, who shows a chronic pattern of aggressive and self-injurious incidents. She used ecological momentary assessments to self-rate challenging behaviors daily for 560 days. CONCLUSIONS: A qualitative summary of caretaker records revealed many internal and environmental factors relevant to her daily life. Her clinician narrowed these down to 11 staff hypothesized risk- and protective factors, such as reliving trauma, experiencing pain, receiving medical care or compliments. Coercive measures increased the chance of challenging behavior the day after and psychological therapy sessions decreased the chance of self-injury the day after. The majority of contemporaneous and lagged associations between these 11 factors and self-reported challenging behaviors were non-significant, indicating that challenging behaviors are not governed by mono-causal if-then relations, speaking to its complex nature. Despite this complexity there were patterns in the temporal ordering of incidents. Aggression and self-injury occurred on respectively 13% and 50% of the 560 days. On this timeline 11 distinct stable phases were identified that alternated between four unique states: high levels of aggression and self-injury, average aggression and self-injury, low aggression and self-injury, and low aggression with high self-injury. Eight out of ten transitions between phases were triggered by extraordinary events in her environment, or preceded by increased fluctuations in her self-ratings, or a combination of these two. Desirable patterns emerged more often and were less easily malleable, indicating that when she experiences bad times, keeping in mind that better times lie ahead is hopeful and realistic.

Are Genetic and Environmental Risk Factors for Psychopathology Amplified in Children with Below-Average Intelligence? A Population-Based Twin Study.

There is a negative association between intelligence and psychopathology. We analyzed data on intelligence and psychopathology to assess this association in seven-year-old Dutch twin pairs (ranging from 616 to 14,150 depending on the phenotype) and estimated the degree to which genetic and environmental factors common to intelligence and psychopathology explain the association. Secondly, we examined whether genetic and environmental effects on psychopathology are moderated by intelligence. We found that intelligence, as assessed by psychometric IQ tests, correlated negatively with childhood psychopathology, as assessed by the DSM-oriented scales of the Child Behavior Check List (CBCL). The correlations ranged between - .09 and - .15 and were mainly explained by common genetic factors. Intelligence moderated genetic and environmental effects on anxiety and negative affect, but not those on ADHD, ODD, and autism. The heritability of anxiety and negative affect was greatest in individuals with below-average intelligence. We discuss mechanisms through which this effect could arise, and we end with some recommendations for future research.

Evaluating the Effectiveness of Take it Personal!+ in People With Mild Intellectual Disability or Borderline Intellectual Functioning and Substance Use Disorder: A Multiple Baseline Single-Case Experimental Study.

Individuals with mild intellectual disabilities or borderline intellectual functioning are at increased risk to develop a substance use disorder-however, effective treatment programs adapted to this target group are scarce. This study evaluated the effectiveness of Take it Personal!+ in individuals with mild intellectual disabilities or borderline intellectual functioning and substance use disorder. Take it Personal!+ is a personalized treatment based on motivational interviewing and cognitive-behavioral therapy supported by an mHealth application. Data were collected in a nonconcurrent multiple baseline single-case experimental design across individuals with four phases (i.e., baseline, treatment, posttreatment, and follow-up). Twelve participants were randomly allocated to baseline lengths varying between 7 and 11 days. Substance use quantity was assessed during baseline, treatment, and posttreatment with a daily survey using a mobile application. Visual analysis was supported with statistical analysis of the daily surveys by calculating three effect size measures in 10 participants (two participants were excluded from this analysis due to a compliance rate below 50%). Secondary, substance use severity was assessed with standardized questionnaires at baseline, posttreatment, and follow-up and analyzed by calculating the Reliable Change Index. Based on visual analysis of the daily surveys, 10 out of 12 participants showed a decrease in mean substance use quantity from baseline to treatment and, if posttreatment data were available, to posttreatment. Statistical analysis showed an effect of Take it Personal!+ in terms of a decrease in daily substance use in 8 of 10 participants from baseline to treatment and if posttreatment data were available, also to posttreatment. In addition, data of the standardized questionnaires showed a decrease in substance use severity in 8 of 12 participants. These results support the effectiveness of Take it Personal!+ in decreasing substance use in individuals with mild intellectual disabilities or borderline intellectual functioning.

The association between mental health problems and asthma among European school children

Background and objectives To examine the prevalence of two ISAAC (International Study of Asthma and Allergies in Childhood) asthma indicators in 7 European countries and their relationship with mental health disorders in children 6–12 years. Methods A cross-sectional survey of 5712 school children aged 6–12 years using a video Self-administered instrument: Dominic Interactive and the Strengths and Difficulties Questionnaire (SDQ) for parents and teachers. Asthma indicators were 12 month “Wheezing or whistling in the chest” (WWC) and “Severe Asthma” (SA) based on number of attacks of wheezing, sleep disturbance due to wheezing, and limits to speech. Results On average 7.31% of the children had WWC, from 15.09% in Turkey to 1.32% in Italy; SA 2.22% on average ranged from 4.78% in Turkey to 0% in Italy. Generalized Anxiety Disorder (GAD) from child self-reports was significantly associated with WWC and SA even after adjustment for covariates. Based on parent and teacher combined reports, emotional problems were found to have significant associations with 12-month WWC after adjustment, as well as “any problems” which summarized externalizing and internalizing disorders Emotional, hyperactivity, conduct disorders were not associated with SA. Conclusion Asthma indicators very much differ across countries. Asthma indicators are associated with childhood GAD. Childhood self-reported mental health seems more related to Asthma indicators than parents/teachers combined reports. (AU)

The geometry of synchronization: quantifying the coupling direction of physiological signals of stress between individuals using inter-system recurrence networks.

In the study of synchronization dynamics between interacting systems, several techniques are available to estimate coupling strength and coupling direction. Currently, there is no general 'best' method that will perform well in most contexts. Inter-system recurrence networks (IRN) combine auto-recurrence and cross-recurrence matrices to create a graph that represents interacting networks. The method is appealing because it is based on cross-recurrence quantification analysis, a well-developed method for studying synchronization between 2 systems, which can be expanded in the IRN framework to include N > 2 interacting networks. In this study we examine whether IRN can be used to analyze coupling dynamics between physiological variables (acceleration, blood volume pressure, electrodermal activity, heart rate and skin temperature) observed in a client in residential care with severe to profound intellectual disabilities (SPID) and their professional caregiver. Based on the cross-clustering coefficients of the IRN conclusions about the coupling direction (client or caregiver drives the interaction) can be drawn, however, deciding between bi-directional coupling or no coupling remains a challenge. Constructing the full IRN, based on the multivariate time series of five coupled processes, reveals the existence of potential feedback loops. Further study is needed to be able to determine dynamics of coupling between the different layers.

How pubertal timing and self-regulation predict adolescent sexual activity in resource-poor environments.

Studies found support for a link between pubertal timing and self-regulation in low-resource environments. This link could potentially explain a link between pubertal timing and early risk behavior. This study builds on this body of research by examining the mediated effect of pubertal timing on sexual activity through self-regulation in 728 adolescents and their families in a group with poor resources and a group with adequate resources. Income-to-Needs (ITN) was measured at age 7.5 to establish two groups (low-ITN and Medium/High-ITN). Pubertal timing was measured at age 10.5, self-regulation was assessed at age 14 and operationalized with effortful control, and sexual activity was assessed at age 16. Structural equation modeling was employed to test the hypothesized model in both groups. The link between pubertal timing and sexual activity mediated by effortful control was only significant in the low-ITN group. Specifically, more advanced pubertal maturity was associated with lower levels of adolescents' effortful control, which in turn was associated with more sexual activity at age 16. Findings were partially replicated with a drug use index replacing sexual activity. This study shows a different operating link from pubertal timing to effortful control and subsequent risk behavior in resource-poor environments. Implications are discussed.

The feasibility of daily monitoring in adolescents and young adults with mild intellectual disability or borderline intellectual functioning.

BACKGROUND: It is unclear whether the limitations of young persons with a mild intellectual disability or borderline intellectual functioning preclude feasibility of the daily diary method. METHOD: For 60 consecutive days, 50 participants (Mage = 21.4, 56% male) who receive care in an ambulatory, residential, or juvenile detention setting, self-rated both standardised and personalised diary questions through an app. Diary entries were used for feedback in treatment. Interviews were used to explore acceptability. RESULTS: Average compliance was 70.4%, while 26% of participants dropped out. Compliance was good in ambulatory (88.9%) and residential care (75.6%), but not in the juvenile detention setting (19.4%). The content of self-selected diary items varied widely. Participants deemed the method acceptable. CONCLUSIONS: Daily monitoring is feasible for individuals with a mild intellectual disability or borderline intellectual functioning receiving ambulatory or residential care, and can provide scientists and practitioners with important insights into day-to-day behavioural patterns.

Building high-quality interpersonal staff-client relationships with people with severe to profound intellectual disabilities and challenging behavior: Insights of professionals and relatives.

Background: Staff-client relationships impact the quality of support and life of people with severe to profound intellectual disabilities and challenging behavior, but are challenging to build due to clients' intense, complex and varying support needs. The present study explores the perspectives of professionals and relatives on what affects these interpersonal relationships. Method: 17 professionals and 11 relatives participated in focus groups and interviews. Data collection and analysis was performed in collaboration with a co-researcher. Data were synthesized thematically. Results: Interpersonal relationships constituted equivalence, striving for mutual understanding, trust and exploring clients' potential. The combination of staff characteristics (enthusiasm/passion, patience, resilience, creativity/humor, flexibility) and expertise (knowledge, vulnerability/sincerity, self-reflection) enabled staff to build these relationships. The importance of involving relatives was addressed. Contextual influences included the team (cooperation, flexibility, culture), organization (cooperation, boundary conditions) and setting (predictability, interior/atmosphere). Conclusions: The findings make practical knowledge explicit and scientifically underpinned for this specific population.

Drug use talk in adolescent friendship interactions: Long-term effects of social learning on lifetime diagnosed substance use disorders.

Adolescence is a critical period of substance use and substance use disorders (SUD). Social exchanges within the context of adolescent friendships are key to understanding peer influences on the development of SUD. In this study we tested whether dyadic conversations between friends at age 17 are predictive of lifetime SUD diagnosis assessed at age 27. In controlled lab sessions, we observed conversations of 497 17-year-old adolescents and a friend. We coded the general way adolescents talk about deviant actions (i.e., deviancy training), but also specific positive talk about drugs (i.e., drug use talk). At age 27, a diagnostic interview was completed to assess lifetime SUD. Independent sample t-tests (in a selection of substance naïve participants to rule out that potential links would be driven by previous substance use) and structural equation modeling (integrated models, controlling for relevant covariates) were used to test whether deviancy training and/or drug use talk were predictive of lifetime SUD-diagnosis 10 years later. No significant links were found between deviancy training and SUD. Independent sample t-tests and integrated models showed significant associations between drug use talk about alcohol and alcohol use disorder and between drug use talk about cannabis use and cannabis use disorder. The link between talking about hard drugs and hard drug use disorder was marginally significant. Findings illustrate the risk of adolescent social learning in drug use talk with friends based on only 10 minutes of interaction, on the prediction of lifetime SUD assessed 10 years later and informs early interventions to curtail development of SUD. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Why adolescents engage in early alcohol use: A study of drinking motives.

Shortly after young adolescents initiate alcohol use, we investigated whether (1) drinking motives are associated with current alcohol use and binge drinking, (2) motives predict these alcohol outcomes 6 months later, and (3) alcohol outcomes predict motives 6 months later. Data on adolescents' drinking motives and alcohol use were drawn from a Dutch longitudinal 7-wave family study at the timepoint of alcohol use initiation (t0, N = 210, 51.4% male, Mage = 14.01 SD = 1.02) and 6 months later (t1, n = 88). Logistic and linear regressions were conducted. Results indicated that young adolescents mainly drink for social and enhancement motives rather than coping and conformity motives. Shortly after alcohol initiation, social motives were associated with alcohol use at t0 (OR = 1.52), enhancement motives with binge drinking at t0 (OR = 2.35), and coping motives with binge drinking at t0 (OR = 2.62) and at t1 (OR = 3.00). Conformity motives were inversely associated with binge drinking at t0 (OR = 0.42). Binge drinking predicted coping motives at t1 (B = 0.71, SE = -0.35), but no other associations among alcohol use, binge drinking, and drinking motives at t1 were found. Conclusively, this study shows that young adolescents drink to enjoy parties and to get drunk (social and enhancement motives) rather than to fit in (conformity motives). The study also indicates that shortly after alcohol initiation, alcohol to cope represents a reciprocal risk factor for binge drinking that may persist in the future, thus pointing to the importance of drinking motives for drinking behaviors among young adolescents. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The Additive Effect of CBT Elements on the Video Game 'Mindlight' in Decreasing Anxiety Symptoms of Children with Autism Spectrum Disorder.

The aim of the present study was to examine the additive effect of elements of cognitive behavioral therapy (CBT) on the video game Mindlight in decreasing anxiety of children with an autism spectrum disorder (ASD). A non-concurrent multiple baseline design with 8 children with ASD in the age of 8-12 was used. CBT did not have the hypothesized additive effect on Mindlight in decreasing anxiety of children with ASD. Instead, multiple participants already experienced a decrease in anxiety during the Mindlight sessions. Yet, several participants did experience a stabilization in anxiety at a low level during the CBT sessions. For now, it can be concluded that CBT does not have an additive effect on Mindlight.

Effectiveness of the online mindset intervention 'The Growth Factory' for adolescents with intellectual disabilities.

BACKGROUND: This study examines participant satisfaction and effectiveness of the online mindset intervention 'The Growth Factory' (TGF) for youth with intellectual disabilities using a randomised controlled trial design. METHOD: Youth with mild to borderline intellectual disabilities (N = 119; 12-23 years) were randomly assigned to TGF (n = 60) or control group (n = 59). Primary outcome measures were mindsets and perseverance. Secondary outcomes were empowerment, mental health problems, self-esteem, treatment motivation, therapeutic alliance and challenge seeking. Measurements were conducted at pre-test, post-test and at 3 and 6 months follow-up. RESULTS: TGF had positive effects on perseverance, mental health problems, self-esteem and therapeutic alliance at post-test. TGF had follow-up effects on mental health problems (3 months), mindset of intelligence (3 and 6 months) and mindset of emotion and behaviour (6 months). CONCLUSIONS: TGF offers a promising add-on intervention complementing usual care programmes accelerating improvements in mindsets and mental health in youth with intellectual disabilities.

Investigating the association between smoking, environmental tobacco smoke exposure and reward-related brain activity in adolescent experimental smokers.

Reduced anticipatory reward-related activity, especially in the ventral striatum (VS), may underly adolescent vulnerability to develop nicotine dependence. It remains unclear whether nicotine uptake caused by environmental tobacco smoke (ETS) exposure, known to be associated with future smoking, might prompt similar changes in the brain's reward system, rendering adolescents vulnerable for development of nicotine dependence. To address this question, we tested whether current ETS exposure and monthly smoking are associated with VS hypoactivity for non-drug rewards in experimental smoking adolescents. One-hundred adolescents performed a monetary incentive delay task while brain activity was measured using fMRI. To test the hypothesized relationship, we used a variety of approaches: (1) a whole-brain voxel-wise approach, (2) an region-of-interest approach in the VS using frequentist and Bayesian statistics and (3) a small volume voxel-wise approach across the complete striatum. The results converged in revealing no significant relationships between monthly smoking, ETS exposure and reward-related brain activation across the brain or in the (ventral) striatum specifically. However, Bayesian statistics showed only anecdotal evidence for the null hypothesis in the VS, providing limited insight into the (non-)existence of the hypothesized relationship. Based on these results, we speculate that blunted VS reward-related activity might only occur after relatively high levels of exposure or might be associated with more long term effects of smoking. Future studies would benefit from even larger sample sizes to reliably distinguish between the null and alternative models, as well as more objective measures of (environmental) smoking via using devices such as silicone wristbands.

Self-reported fears and mental health in elementary school children across Europe.

Fears are common in the general population and particularly among children. The number of fear subtypes (animals, natural environment, situational, blood-injection-injury or other type) has been shown to be associated with psychopathology. Furthermore, there is evidence suggesting that some subtypes may be more often associated with mental disorders than others. The present study uses data from a large cross sectional survey, the School Children Mental Health in Europe (SCMHE) study, conducted in eight European countries on children ages 6 through 13-years-old attending elementary school (n = 9613). Fear subtypes and self-reported mental health were assessed using the Dominic Interactive (DI), a self-administered computerized image-based questionnaire. The findings show that the number of fear subtypes is strongly associated with self-reported internalizing and externalizing problems. In addition, adjusting for the number of subtypes, fear of animals was less likely than other fears to be associated with psychopathology. The findings support the notion that children who report excessive and generalized fear should be targeted for prevention, consistent with research identifying childhood onset generalized specific phobia as a probable precursor to subsequent psychopathology.

The mediating role of substance use motives in the relationship between personality dimensions and alcohol and drug use in adolescents and young adults with mild intellectual disabilities.

Adolescents and young adults with mild intellectual disabilities or borderline intellectual functioning (MID-BIF) are a high-risk group for developing substance use disorders. The aim of this study was to gain a better understanding of the mechanisms that underlie substance use in this particular population. We tested the mediating role of substance use motives in the relationship between personality dimensions and substance use-related outcomes. Self-reported data on substance use risk personality dimensions (i.e., sensation seeking, impulsivity, anxiety sensitivity, and negative thinking), substance use motives (i.e., social, enhancement, coping, and conformity motives), and substance use were obtained from 163 individuals with MID-BIF (mean age 18.9 years). Results show that coping motives played a main role in the associations between personality dimensions and substance use in adolescents and young adults with MID-BIF, with significant relationships between impulsivity and negative thinking and severity of alcohol use or drug use via coping motives. Moreover, findings indicated a relatively high risk for several substance use motives and associated substance use (disorder) in individuals high on impulsivity. Results show significant relationships between impulsivity and severity of alcohol use or drug use via social, enhancement, and coping motives. No mediating associations were found for conformity motives, nor did we find any mediation associations in individuals with high levels of anxiety sensitivity. These insights provide the possibility of tailoring interventions to specific motives that underlie substance use in different types of users with MID-BIF based on personality dimensions.

Bullying involvement and suicidal ideation in elementary school children across Europe.

BACKGROUND: Bullying involvement is associated with suicidal ideation among adolescents, yet there are no studies examining this issue among younger children. METHODS: The School Children Mental Health in Europe study was conducted in seven countries in 2010 using similar methods to collect cross-sectional data from children, parents, and teachers. Suicidal ideation and thoughts of death were assessed using the Dominic Interactive among children. Parent and teacher reports were used to determine bullying involvement. The sample comprised n = 5,183 children ages 6 to 11 identified as bullies (n = 740, 14.3%), victims (n = 945, 18.2%), bully-victims (n = 984, 18.2%) and not involved in bullying (n = 2,514, 48.5%). Multivariate logistic regressions were used to assess the association of bullying involvement with suicidal ideation and thoughts of death. RESULTS: Suicidal ideation was reported by 13.3% of those not involved in bullying, 17.1% of victims, 19.6% of bullies and 24.4% of bully-victims. Similarly, thoughts of death were reported by 19.0% of victims, 24.3% of bullies, and 25.0% of bully-victims. Children identified as being involved were more likely than those not involved to report suicidal ideation in bivariate analyses. When controlling for psychopathology and for maternal distress among other factors, the association remained significant for bullies (AOR=1.30, 95%CI=1.01-1.66), bully-victims (AOR=1.54, 95%CI=1.22-1.94), but not for victims (AOR=1.02, 95%CI=0.80-1.30). LIMITATIONS: The study is cross-sectional. The assessment of bullying may have underestimated victimization. CONCLUSIONS: The association of bullying involvement and child suicidal ideation is present among elementary school children across Europe, using multiple informants to avoid shared variance biases, and adjusting for key factors.

Effectiveness of game-based meditation therapy on neurobiological stress systems in adolescents with posttraumatic symptoms: a randomized controlled trial.

Many adolescents in residential care have experienced traumatic events and suffer from posttraumatic stress. Prolonged activation of neurobiological stress systems as the autonomic nervous system (ANS) and the hypothalamic-pituitary-adrenal (HPA) axis can result in long-lasting maladaptive alternations. This study investigated the effectiveness of Muse, a game-based meditation intervention, on the sympathetic nervous system (SNS), parasympathetic nervous system (PNS), and cortisol basal activity and reactivity to acute stress among adolescents with posttraumatic symptoms in residential care. The intervention consisted of two gameplay sessions a week, for 6 consecutive weeks. Seventy-seven adolescents with clinical levels of posttraumatic symptoms (10-18 years old) received either Muse as an addition to treatment as usual (n = 40) or treatment as usual alone (n = 37). We expected reduced basal activity for the SNS and cortisol and increased basal activity for the PNS. As for the response to acute stress, we expected decreased PNS and increased HPA axis reactivity. The Muse group exhibited lower basal activity for the SNS and increased HPA reactivity to acute stress. There were no differences between conditions on SNS and HPA axis activity during rest and on SNS and PNS reactivity to acute stress. Game-based meditation therapy is a promising intervention for the treatment of adolescents with posttraumatic symptoms in residential care. Implications for clinical relevance and trauma-focused treatment purposes are discussed.

Implementation of a proactive referral tool for child healthcare professionals to encourage and facilitate parental smoking cessation in the Netherlands: a mixed-methods study.

BACKGROUND: Recently, the parent-tailored telephone based smoking cessation counseling program 'Smoke-free Parents' was shown to be effective in helping parents to quit smoking. To implement this program in child healthcare settings in the Netherlands, the research team developed a proactive referral tool to refer parents to Smoke-free Parents. The aim of the present implementation study was to explore the facilitators, barriers, and suggestions for improvement in the implementation of this referral tool. METHODS: Child healthcare professionals (N = 68) were recruited via multiple strategies (e.g., social media, mailings, and word of mouth among healthcare professionals) and invited to complete two online (quantitative and qualitative) questionnaires and to participate in a telephone semi-structured qualitative interview between April 2017 and February 2019. In total, 65 child healthcare professionals were included in the analyses. After inductive coding, thematic analyses were performed on the qualitative data. Descriptive analyses were performed on the quantitative data. RESULTS: The data from both questionnaires and the telephone interview revealed that the majority of the child healthcare professionals (92.3 % female; average years of working as a healthcare professional: 23.0) found the Smoke-free Parents referral tool accessible and convenient to use. Yet there were several barriers that limited their use of the tool. The data revealed that one of the main barriers that healthcare professionals experienced was parental resistance to smoking cessation assistance. In addition, healthcare professionals noted that they experienced tension when motivating parents to quit smoking, as they were not the parent's, but the child's healthcare provider. Additionally, healthcare professionals reported being concerned about the lack of information about the costs of Smoke-free Parents, which limited professionals referring parents to the service. CONCLUSIONS: Although healthcare professionals reported rather positive experiences with the Smoke-free Parents referral tool, the use of the tool was limited due to barriers. To increase the impact of the Smoke-free Parents telephone-based smoking cessation counseling program via child healthcare settings, it is important to overcome these barriers. Suggestions for improvement in the implementation of the referral tool in child healthcare settings are discussed.

Physiological Measurements of Stress Preceding Incidents of Challenging Behavior in People With Severe to Profound Intellectual Disabilities: Longitudinal Study Protocol of Single-Case Studies.

BACKGROUND: Clients with severe to profound intellectual disabilities (SPID) and challenging behavior (CB) and the professional caregivers that support them are vulnerable to high stress levels, which negatively impact their well-being and the quality of care. CB is thought to result from an increase in the intensity and frequency of clients' stress experiences. In turn, staff members experience stress in dealing with this behavior, and stressed staff members might behave in ways that increase clients' stress levels, contributing to the origin and maintenance of CB. Research into these dyadic interactions between clients and staff is scarce for people with SPID, especially in real-life situations. The barriers of studying stress in this population include clients' difficulties in communicating stress experiences and the lack of an objective continuous measure of stress. OBJECTIVE: This paper presents a protocol for studying patterns of physiological stress in 15 client-caregiver dyads in the 30 minutes preceding incidents of CB compared to control periods without CB and the interplay between the stress levels of clients and professional caregivers. METHODS: We will conduct 15 single-case studies to assess patterns of physiological stress in dyads of clients with SPID and professional caregivers prior to CB in several Dutch residential institutes. Client-caregiver dyads will wear the Empatica E4 wristband for 20 sessions of 3 to 8 hours without interruptions of daily routines while caregivers report clients' CB. The physiological measures obtained will be electrodermal activity (microsiemens) and heart rate (beats per minute). A multilevel model with repeated measures at the incident level nested within the person level will be applied, employing separate models for electrodermal activity and heart rate to compare stress levels in the 30 minutes prior to incidents with control epochs. Covariates in the models include movement, temperature, and gender. In addition, cross-recurrence quantification analyses will be performed to study the synchronization between the stress levels of clients and professional caregivers. RESULTS: The Ethics Committee of the Radboud University (NL-number: NL71683.091.19) approved the study on February 12, 2020. In total, 15 organizations have declared their commitment to participate in the study. The first result is expected in the spring of 2022. CONCLUSIONS: Study results will demonstrate whether changes in patterns of electrodermal activity and heart rate are apparent in the 30 minutes preceding an incident of CB compared to baseline levels when the client does not engage in CB. The synchronization between caregivers' and clients' physiological stress levels will be explored with cross-recurrence quantification analyses. Insights into the physiological stress levels of clients and caregivers may contribute to a reduction of CB and an improvement of both clients' and caregivers' safety and well-being. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/24911.