Changes

April 2025 — minor update. QOF indicators removed in line with NHS England's 2025 Quality and Outcomes Framework.

Update

Goals

To support primary healthcare professionals to:

• Refer a person for specialist confirmation of a diagnosis if a learning disability is suspected.
• Provide support and advice for a person with a confirmed learning disability and to their family members/carers.
• Ensure the person has an annual health check in either primary or secondary care, and is provided with a health action plan.
• Provide support and management for behaviour that challenges and/or a mental health problem, aligned with specialist advice where needed.
• Prescribe antipsychotic drug treatment, if needed, as part of a shared care agreement with the person's specialist team.

Outcome measures

Audit criteria

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

NICE quality standards relating to people with a learning disability and behaviour that challenges which may be relevant to this CKS topic include:

• Quality statement 2. People with a learning disability have an annual health check from their GP.
• Quality statement 3.  People with a learning disability and behaviour that challenges have an initial assessment to identify possible triggers, environmental factors and function of the behaviour.
• Quality statement 4. People with a learning disability and behaviour that challenges have a named lead practitioner.
• Quality statement 5. Families and carers of a person with a learning disability and behaviour that challenges are involved in developing the person's care and support plan, which includes how to prevent or respond to a crisis.
• Quality statement 6. Parents or carers of children aged under 12 years with a learning disability and behaviour that challenges are offered a parent-training programme.
• Quality statement 7. People with a learning disability and behaviour that challenges take part in personalised daily activities.
• Quality statement 8. People with a learning disability and behaviour that challenges have access to specialist behavioural support in the community.
• Quality statement 11. People with a learning disability and behaviour that challenges only receive antipsychotic medication as part of treatment that includes psychosocial interventions.
• Quality statement 12. People with a learning disability and behaviour that challenges have a multidisciplinary review of their antipsychotic medication 12 weeks after starting treatment and then at least every 6 months.

[NICE, 2019]

NICE quality standards relating to people with a learning disability and mental health problems which may be relevant to this CKS topic include:

• Quality statement 1. Young people and adults with a learning disability have an annual health check that includes a review of mental health problems.
• Quality statement 2. People with a learning disability who need a mental health assessment are referred to a professional with expertise in mental health problems in people with learning disabilities.
• Quality statement 3. People with a learning disability and a serious mental illness have a key worker to co-ordinate their care.
• Quality statement 4. People with a learning disability and mental health problems who are receiving psychological interventions have them tailored to their preferences, level of understanding, and strengths and needs.
• Quality statement 5. People with a learning disability who are taking antipsychotic drugs that are not reduced or stopped have annual documentation on reasons for continuing this prescription.

[NICE, 2017]

NICE quality standards relating to people with a learning disability and decision making and mental capacity which may be relevant to this CKS topic include:

• Quality statement 1. People aged 16 and over who may lack capacity to make decisions are supported with decision making in a way that reflects their individual circumstances and meets their particular needs.
• Quality statement 2. People aged 16 and over at risk of losing capacity to make decisions, and those with fluctuating capacity, are given the opportunity to discuss advance care planning at each health and social care review.
• Quality statement 3. People aged 16 and over who are assessed as lacking capacity to make a particular decision at the time that decision needs to be made, have a clear record of the reasons why they lack capacity and the practicable steps taken to support them.
• Quality statement 4. People aged 16 and over who lack capacity to make a particular decision at the time that decision needs to be made have their wishes, feelings, values, and beliefs accounted for in best interests decisions.

[NICE, 2020]

What is it?

• The National Institute for Health and Care Excellence (NICE) advises that a learning disability is defined by three core criteria [NICE, 2015]:
  • Lower intellectual ability (usually an IQ of less than 70).
  • Significant impairment of social or adaptive functioning.
  • Onset in childhood.
  • Note: the term 'intellectual disability' is becoming increasingly used internationally.
• The UK Department of Health and Social Care (DHSC) defines a learning disability as [DHSC, 2001]:
  • 'A significantly reduced ability to understand new or complex information, to learn new skills (impaired intelligence), with a reduced ability to cope independently (impaired social functioning), which started before adulthood'.
• A learning disability differs from a 'learning difficulty', which is [PHE, 2023]:
  • 'A reduced intellectual ability for a specific form of learning and includes conditions such as dyslexia (reading), dyspraxia (affecting physical co-ordination) and attention deficit hyperactivity disorder (ADHD).  A person with a learning disability may also have one or more learning difficulties'.
• The International Classification of Diseases 11th Revision (ICD-11) classifies the severity of learning disabilities as [WHO, 2022]:
  • Mild — approximate IQ range of 50 to 69. Likely to result in some difficulties in the acquisition and comprehension of complex language concepts and academic skills. Most people can manage basic self-care, domestic, and practical activities, and can live and work relatively independently, but may require appropriate support.
  • Moderate — approximate IQ range of 35 to 49. Likely to have basic language and academic skills, but some will manage basic self-care, domestic, and practical activities. Most will need considerable and consistent support to live and work independently.
  • Severe — approximate IQ range of 20 to 34. Have very limited language and academic skills and may also have motor impairments. Typically need daily support in a supervised environment for adequate care, but may acquire basic self-care skills with intensive training.
  • Profound — IQ under 20. Results in very limited communication skills and may have basic concrete skills. May have motor and sensory impairments, and typically need daily support in a supervised environment for adequate care.

How common is it?

• Public Health England (PHE) estimates there are about 1.3 million people with a learning disability in England, including over 950,000 adults aged 18 years or over. The number of people with learning disabilities recorded in health and welfare systems is much lower [PHE, 2023].
• Data analysis from 55.7% of patients registered with a GP practice in England in 2021–2022 showed that 0.5% of patients in primary care were recorded as having a learning disability by their GP [NHS Digital, 2022].
• In 2018, 67,765 children in England had an education, health and care plan and were identified as having a primary special educational need associated with learning disabilities. Of these [PHE, 2020]:
  • 28,241 had moderate learning difficulties.
  • 29,492 had severe learning difficulties.
  • 10,032 had profound multiple learning difficulties.
  • The majority of children with moderate, severe, and profound multiple learning difficulties were boys.
  • 26% were being educated in a mainstream school.

What are the risk factors?

• A person is more likely to have a learning disability if there is a risk factor which affects the development of the brain before birth, during birth, or in early childhood [PHE, 2023]:
  • Some chromosomal and genetic anomalies — such as Down's syndrome, Turner syndrome, Williams syndrome, Rett's syndrome, Fragile X syndrome.
  • Some non-genetic congenital malformations — such as some forms of spina bifida, hydrocephalus, microcephaly.
  • Prenatal exposures — including alcohol, sodium valproate, congenital rubella infection, Zika virus infection.
  • Birth complications resulting in hypoxic brain injury or cerebral palsy.
  • A very premature birth (usually less than 33 weeks' gestation).
  • Childhood illness — such as meningitis, encephalitis, measles, epilepsy. See the CKS topics on Meningitis - bacterial meningitis and meningococcal disease, Measles, and Epilepsy for more information.
  • Childhood brain injury or trauma including non-accidental injury. See the CKS topic on Child maltreatment - recognition and management for more information.
  • Childhood neglect and/or lack of stimulation in early life.
  • Neurodevelopmental disorders such as autism and attention deficit hyperactivity disorder (ADHD). See the CKS topics on Autism in children, Autism in adults, and Attention deficit hyperactivity disorder for more information.
• A person with a learning disability is more at risk of behaviour that challenges if there are [NICE, 2015]:
  • Personal factors
    • Typical age (incidence peaks in teenagers and people in their early 20s).
    • A severe learning disability.
    • Autism. See the CKS topics on Autism in children and Autism in adults for more information.
    • Mental health problems including dementia. See the CKS topic on Dementia for more information.
    • Communication difficulties (expressive and receptive).
    • Sensory impairments (visual impairment may lead to increased self-injury and stereotypy).
    • Sensory processing difficulties.
    • Physical health problems.
  • Environmental factors
    • Care environments with limited opportunity for social interaction and meaningful activity, low engagement with staff, lack of choice, or excessive sensory stimulation such as noise, heat, light, and smell.
    • Care environments which are crowded, unresponsive, or unpredictable; characterized by abuse or neglect; or physical health needs such as pain are unmet. See the CKS topic on Child maltreatment - recognition and management for more information.
    • Developmentally inappropriate care environments (for example, an educational curriculum that makes too many demands on a child or young person).
    • Care environments where disrespectful social relationships and poor communication are typical, or where staff do not have the capacity or resources to respond to people's needs.
    • Changes to the person's environment (for example significant staff changes or moving to a new care setting).

Which conditions may be associated?

A person with a learning disability may have associated conditions, but these may be under-diagnosed due to difficulties in interpreting symptoms, atypical presentations, difficulties in communication, and difficulties accessing healthcare services.

• Behaviour that challenges (affects around 5–15% of people in educational, health, or social care settings). It may include [NICE, 2015]:
  • Aggression, harm to others.
  • Self-injury, self-harm. See the CKS topic on Self-harm for more information.
  • Stereotypy (repeated behaviours such as rocking or hand flapping).
  • Social withdrawal. 
  • Disruptive or destructive behaviour, including violence, arson, or sexual abuse, which may bring the person into contact with the criminal justice system. See the CKS topic on Conduct disorders in children and young people for more information.
  • Note: 'behaviour that challenges' is not a diagnosis and may serve a purpose for the person, such as producing sensory stimulation, attracting attention, avoiding demands, and providing a means of communication. It may also be an indicator of a physical health problem such as pain [NICE, 2015; PHE, 2023].
• Physical health problems (affect around 50% of people). These may include [CIPOLD, 2013; NHS England, 2017; PHE, 2023]:
  • Obesity or being underweight (related to diet, activity, and access to healthy lifestyle advice and support). See the CKS topic on Obesity for more information.
  • Epilepsy. See the CKS topic on Epilepsy for more information.
  • Dysphagia, increased risk of aspiration pneumonia.
  • Constipation, bladder and bowel continence issues, reflux disease, thyroid disorders, congenital heart problems, osteoporosis. See the CKS topics on Constipation in children, Constipation, GORD in children, Dyspepsia - proven GORD, Faecal incontinence in adults, Hypothyroidism, Incontinence - urinary, in women, Osteoporosis - prevention of fragility fractures, Incontinence - urinary, in women for more information.
  • Cancer.
  • Type 2 diabetes mellitus and cardiovascular disease. See the CKS topics on Diabetes - type 2 and CVD risk assessment and management for more information.
  • Visual and hearing impairment.
• Mental health problems (point prevalence of around 30%) [RCPsych, 2016]. These may include [NICE, 2016b; NHS England, 2017; PHE, 2023]:
  • Anxiety and phobias. See the CKS topics on Generalized anxiety disorder and Obsessive-compulsive disorder for more information.
  • Depression, suicidal ideation, self-harm, self-neglect. See the CKS topics on Depression in children, Depression, and Self-harm for more information.
  • Psychosis, schizophrenia. See the CKS topic on Psychosis and schizophrenia for more information.
  • Bipolar disorder. See the CKS topic on Bipolar disorder for more information.
  • Dementia (increased prevalence of early-onset dementia in people with Down's syndrome). See the CKS topic on Dementia for more information.
  • Note: mental health problems may develop and present differently than in people without a learning disability [NICE, 2016b].
• Other — more likely to:
  • Live in rented and/or overcrowded and/or poor standard housing — around 60% of children and young people with a learning disability live in poverty [PHE, 2023].
  • Be a looked-after child; receiving social support [NICE, 2016b].
  • Use tobacco, alcohol, and recreational drugs [NHS England, 2017].
  • Be under- or unemployed — in 2017–18, 6% of working age adults with a learning disability in England receiving long-term social care support were in paid or self-employment [PHE, 2020].
  • Be subject to bullying and discrimination, social stigma and exclusion, maltreatment and/or exploitation  [NICE, 2015; PHE, 2023]. See the CKS topic on Child maltreatment - recognition and management for more information.
  • Have reduced social support and increased loneliness compared with the general population [PHE, 2023].

What is the prognosis?

People with a learning disability have a shorter life expectancy than the general population.

• A learning disability is a lifelong condition which cannot be cured [PHE, 2023].
• The Learning from Lives and Deaths - people with a learning disability and autistic people (LeDeR) 2021 publication found [KCL, 2021]:
  • 6 out of 10 people living with a learning disability died before they were 65 years of age.
  • The median age of death was 61 years, which is an increase by one year compared with deaths notified in 2018 and 2019. On average, men with a learning disability die 22 years earlier than the population average, and women die 26 years earlier than the population average.
  • COVID-19, congenital malformations and chromosomal abnormalities, and cancer were the leading causes of death.
  • People of Black, Black British, Caribbean or African, mixed ethnic group, and Asian or Asian British ethnicity died at a younger age compared with people of white ethnicity.
  • 49% of deaths were rated as 'avoidable', compared with 22% of death in the general population.
• The Confidential Enquiry into premature deaths of people with learning disabilities (CIPOLD) reviewed the deaths of 247 people with learning disabilities in 2010–2012 and found [CIPOLD, 2013]:
  • The most common underlying causes of death were cardiac and circulatory disorders and cancer.
  • The final event leading to death was most commonly a respiratory infection.
  • 43% of the deaths were unexpected.

How should I assess a person with a learning disability?

Most people with a learning disability in primary care will have a diagnosis following a specialist neurodevelopmental assessment. Rarely, children or adults may present in primary care with a suspected learning disability which may be associated with additional risk factors. Assess the person's needs and capacity to make specific decisions throughout their assessment.

• Take a history, taking into account the person's communication needs, developmental stage, level of understanding, and severity of learning disability. Wherever possible and appropriate, communicate with the person directly:
  • Use plain English, short sentences, and avoid medical jargon and acronyms.
  • Check whether they have a hospital passport, which may specify their preferred method of communication with others, such as use of communication aids, an advocate, or someone familiar with the person.
  • Make adjustments to accommodate sensory impairments (including vision and hearing).
  • Consider use of visual aids, objects, practical demonstractions, or gestures to explain concepts.
  • Give the person time to process information before they respond.
  • Use different methods and formats for communication (written, signing, visual, verbal, where possible), depending on the person's preferences, such as Makaton (signs and speech), Talking Mats (symbols), Beyond Words (wordless picture books), or Widgit (symbol-based images). If using written text, use larger, easy to read text where possible.
  • Regularly check the person's understanding by asking open questions.
• Ask the person, their family members and/or carers about:
  • Past or current behaviour and any difficulties with daily living and routine, such as understanding new or complex information, learning new skills, budgeting, planning, and time management.
  • Family and social history including relationships with family members, carers, staff (such as care workers and teachers); any history of attachment difficulties; any history of trauma, neglect, or abuse; need for support with activities of daily living and self-care; smoking, alcohol, and recreational drug use.
  • Developmental history (birth, pregnancy, developmental milestones).
  • Any childhood health conditions.
  • Educational history (types of schools; level of help and support required with reading, writing, or simple numeracy; any education, health and care plan; any qualifications achieved).
  • Occupational history (paid and voluntary).
  • Any physical health problems including difficulties with co-ordination and mobility, bladder or bowel continence; language, communication and interaction; sensory impairments including vision and hearing; sensory processing difficulties.
  • Any cognitive, emotional, psychological, mental health problems, or behaviour that challenges and associated risk factors; problems with concentration and attention; any risk of exploitation, abuse, or neglect by others.
  • Family/carer interpretations of the person’s difficulties.
  • Previous cognitive assessments; help needed interpreting social cues.
  • Current and previous medication and interventions, and response.
  • Input from other professionals (child and adult).
• Examine the person, including:
  • General appearance.
  • Eye contact.
  • Use of vocabulary.
  • Social interaction.
  • Behaviour.

Scenario: Suspected learning disability

From age 1 month onwards.

Scenario: Confirmed learning disability

From age 1 month onwards.

Scenario: Behaviour that challenges and mental health problems

From age 1 month onwards.

Search strategy

Scope of search

A full literature search was not required as this CKS topic is largely based on the National Institute of Health and Care Excellence (NICE) guidelines Challenging behaviour and learning disabilities: prevention and interventions for people with learning disabilities whose behaviour challenges [NICE, 2015], Mental health problems in people with learning disabilities: prevention, assessment and management [NICE, 2016a], Care and support of people growing older with learning disabilities [NICE, 2018a], and Decision-making and mental capacity [NICE, 2018b].

Search dates

October 2018 - March 2023

Key search terms

The terms listed below are the core search terms that were used for EBSCO MEDLINE (searched 29th October 2018). This strategy was adapted for use in The Cochrane Library.

S4 S1 or S2 or S3

S3 AB learning disabilit* OR TI learning disabilit*

S2 (MH "Child Development Disorders, Pervasive+") OR (MH "Developmental Disabilities")

S1 (MH "Intellectual Disability+") 

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Bandolier
• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.