ARC branch meeting Challenging Behaviour

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ARC branch meetingChallenging Behaviour
Positive Behavioural Support
ABM Ymddiriedolaeth Prifysgol GIG Abertawe
Bro Morgannwg University NHS Trust

Dr. Edwin Jones
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People with learning disabilities and challenging
behaviour

• one of the most vulnerable groups in society and
  are at increased risk of social exclusion, abuse,
  inappropriate treatment, deprivation and
  systematic neglect.
• Between 10-15 of the population of people with
  learning disabilities
• Definition
• Culturally abnormal behaviour of such an
  intensity, frequency or duration that the
  physical safety of the person or others is likely
  to be placed in serious jeopardy, or behaviour
  which is likely to seriously limit or deny access
  to and use of ordinary community facilities
  (Emerson, 1995)
• aggression,
• destructiveness,
• self injury,
• Wide range of other behaviours which may be
  harmful to the individual (e.g eating inedible
  objects) and/or challenging for carers and staff
  (e.g. non compliance, persistent screaming,
  disturbed sleep patterns, over-activity,
  stereotyped mannerisms ) and /or objectionable to
  members of the public (e.g. regurgitation of
  food, smearing of faeces, inappropriate sexual
  behaviour).
• the primary risk factor for out of family
  placement and institutionalisation

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The Nature of Challenging Behaviour

• such behaviours represent challenges to
  services rather than problems which individuals
  with learning disabilities carry around with
  them. If services could rise to the challenge
  of dealing with these behaviours , they would
  cease to be problems (Blunden Allen, 1987)
• the competence or capability of local
  mainstream services for people with learning
  disabilities willinfluence the number of people
  defined as presenting a serious challenge. Well
  organised and managed serviceswill show fewer
  problems (Mansell Report, 1993)

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Induction refresher practical training in
work-related skills Practice Leadership Multi-disc
iplinary support Person-centred Proactive
orientation Staff Supervision Active
Support Clear proactive reactive plans Weekly
staff meetings QA system in place Proactive
stress management for staff
No induction training Administrative
leadership Reactive orientation Staff-orientat
ed Low engagement levels Quarterly, optional
staff meetings No staff supervision No auditing
of care plans - last up date 2 years ago No
clear emergency management plans
Challenging Behaviour Service Competence
Severe Self Injury Physical Aggression Smearing
Faeces Pica
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Mansell II

• Investment is required to achieve two aims
  -to develop and expand the capacity of local
  services for people with learning disabilities to
  understand and respond to challenging
  behaviour- to provide specialist services
  locally which can support good mainstream
  practice as well as directly serve a small number
  of people with the most challenging behaviour
• (para.48)

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Mapping study (SPT, 2004)

• 1,458 children and adults identified within the
  Bro Morgannwg LD Directorate area
• At any one point in time, approximately 175 will
  receive input from the Specialist Services (SBT,
  AATU, CHC)
• 80 plus of people who challenge will therefore
  be supported within social care frameworks with
  inputs from CSTs

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Training (Mansell II)

• A key contribution to local capability is that
  staff working with people whose behaviour
  represents a challenge have adequate training.
  Many services at present attempt to deal with the
  challenge they face by adding more and more staff
  at greater and greater cost. (para.87)
• The necessary skills include person-centred
  active support, Positive Behavioural Support,
  Total Communication, Recognising and responding
  to mental health problems, person centred
  planning (para.87)
• NVQs are seen as too general, and too heavily
  influenced by assumptions relevant to services
  for older people, to be as useful as they should
  for staff supporting people with whose behaviour
  presents a challenge. (para. 89)..Greater
  emphasis ought to be possible on the skills
  needed to work with people whose behaviour
  presents a challenge (para. 90)
• Need to develop more relevant, practical training

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Normalisation/ Social Role Valorization

• Getting the good things in life for vulnerable
  devalued people
• Defined the use of culturally valued means in
  order to enable people to live culturally valued
  lives (Wolfensberger, 1980)
• Primary aim is the creation, support and
  defence of valued social roles for people at risk
  of devaluation (Wolfensberger, 1983)
• Major emphasis on the effect of societal process
  such as labelling, segregation and congregation
  of devalued groups in exacerbating the nature of
  a persons disability and the need to change
  these

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Criticisms of SRV/ Normalisation

• Advocates an intervention strategy that lacks a
  scientific baseThe minimal amount of data
  that is available does not suggest the
  applicability of non-specific treatments such as
  normalisation, which basically consists of a
  community placement with a de-emphasis on
  formalised training(Marchetti Matson, 1981)
• Misinterpretations!!!!
• Choice perversion
• Making people normal

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AIMS (service accomplishments)OBrien (1987)

• Community presence
• Choice
• Competence
• Respect
• Participation

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Applied Behaviour Analysis

• Applied in that the behaviours and events should
  be of importance to society
• Behavioural in that research should be concerned
  with what people do
• Analytic in that research should provide a
  believable demonstration of the events that can
  be responsible for the occurrence or no
  occurrence of behaviour, usually by demonstration
  of experimental control
• Technological in that techniques used are
  identified and described in a manner that allows
  replication
• Conceptually Systematic in that procedures used
  are shown to be relevant to basic behavioural
  principles
• Effective in that socially significant changes
  in behaviour are achieved
• General In that the behavioural change proves
  durable over timeappears in a wide variety of
  possible environments or..spreads to a variety of
  related behaviours.
• Evidence based large body of research evidence
  built up over several decades

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Criticisms of ABA

• Represents a dehumanising technology for the
  repressive social control of disabled
  individuals
• Punishment/ aversives most common treatment
  given to people WLD CB
• Use of behavioural approaches is endangering the
  chances of people living ordinary lives (Walker,
  1987)
• Presents a unique set of moral and ethical
  problems relating to the social control of
  others- the aversive debate- the end justifies
  the means vs human rights

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• Like many tools behaviour modification
  techniques are themselves morally blind. Like a
  stout sword, they work equally well in the hands
  of hero or tyrant (Wood, 1983)

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The Origins of PBS
The Aversives Debate
ABA a toolkit with no values base
SRV a values base with no toolkit
Positive Behavioural Support a values-based
toolkit for supporting behaviour change
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Positive Behavioural Support
Applied Behaviour Analysis (Science)
PCP (Philosophy framework)
Normalisation/ SRV (Philosophy)



Positive Behavioural Support
A values-led toolkit for behaviour change
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What can PBS achieve?

• 68 of positive behavioural interventions achieve
  80 or more reduction in behaviour from baseline
  levels
• Produce small to significant changes in adaptive
  behaviour
• Can show significant maintenance over time
• Can result in effective lifestyle change
• More effective if interventions involve
  environmental reorganisation
• More effective if regular carers/ staff deliver
• Better results in environments with active
  programming (day activity, skill development
  etc.)
• Better results in integrated settings

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A PBS Model

• Primary Prevention changing aspects of a
  persons living, working and recreational
  environments so that the possibility of
  aggressive behaviour occurring is reduced.
• Secondary Prevention actively listening for
  early indicators of behaviour and early
  intervention to divert behavioural escalation.
• Reactive Strategiesethical responses to risk
  behaviours that maximise the safety of both
  service users and carers

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Access to Behavioural Support in UK

• Rates of use of behaviour change strategies,
  restraint medication for challenging
  behaviours

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Training Effectiveness SPT PBS Training (Lowe
et al., 2007)

• Vocational qualification, designed originally for
  Directorate staff
• Initial induction then paper based,
  self-instructional mode
• Significant changes in knowledge, most notably
  for unqualified staff
• Significant changes in self-reports of confidence
  in dealing with challenging behaviour, maintained
  over time
• Very positive student evaluations (the quality
  of the course has been excellent given me a
  greater understanding of what is expected of me
  in my new role)
• Very positive evaluations from clinicians

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Our Challenge

• the competence or capability of local
  mainstream services for people with learning
  disabilities willinfluence the number of people
  defined as presenting a serious challenge. Well
  organised and managed serviceswill show fewer
  problems (Mansell Report, 1993)

• How to disseminate the critical skills of PBS
  required for the support of people who challenge
  in the necessary volume and in an accessible,
  cost-effective format?

Effective Training Model Developed
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Our response No easy answers

• Remind
• effective training
• Explain
• why e learning
• Show
• content
• Tell
• how to access

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Human Services

• Most staff
• Dont have formal qualifications
• Dont have key skills when appointed
• Receive little training once in post

Assumption that anyone everyone knows how to
help people with complex needs
Clements Zarkowska (1994)
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Traditional Approaches to Training are ineffective

• Short-course training, in one off blocks, causes
  no disturbance to organisations and established
  systems, it provides staff with time away and
  some material comfort, and it provides trainers
  with powerful social and material reinforcement.
  From a behavioural perspective it is irresistible
  in terms of the reinforcement contingencies
  operating on all those involved
  (Clements, 1993)

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Effective training strategies
Combinations of different training techniques,
reinforced by on-going management attention is
most effective (e.g. Anderson 1987 Jones et al
1987)
3 steps to competence--LaVigna et al (1994)
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3 levels of training

• Advanced/specialist level
• Advanced Professional Diploma in PBS
• senior practitioners, behaviour specialists,
  staff with management leadership
  responsibilities
• Intermediate level
• Advanced Diploma in PBS
• registered nurses, deputy managers, first-line
  managers in social care etc.
• Entry level
• Advanced Certificate in PBS
• nursing assistants, support workers, classroom
  assistants, parents etc.

3 Adv Prof Diploma NVQ 4/5
2 Prof Diploma NVQ 3/4
1 Adv Certificate NVQ 2/3
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Contemporary services

• Small-scale community based
• 5-10,000 staff may require training
• Dispersed geographical area
• Several agencies
• Limited resources
• Difficult expensive to release staff for
  classroom based training
• High staff turnover train frequently
• Variable skills abilities of workforce

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E learning can meet many contemporary service
needs but, its not a panacea!
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Benefits/ advantages of e learning

• Dispersed geographical area
• 5-10,000 staff
• Several agencies
• Limited resources
• Difficult expensive to release staff for
  classroom based training
• High staff turnover train frequently
• Variability in skills abilities of workforce

• Continuous access not limited by time or
  geography across multiple agencies
• In high volume to individuals or groups with
  minimal release from workplace
• Very low-cost to users- after initial development
• Easy access to refresh/ update
• Flexible to suit different learning styles and
  paces

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And theres more ..
Fully addresses first 2 steps to competence and
considered capable of predicting how learners
will perform in practice
Proven to be reliable and highly effective
rapidly enhances problem solving skills
Goodness of fit with the future training delivery
strategies of many progressive support providers
Online assessment support can give immediate
feedback
Provide for more authentic simulations of real
world environments
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Disadvantages/risks of e learning

• Challenges
• Availability of computers
• Access to internet (dialup / broadband?)
• Computer literacy
• Computer phobia
• Cannot achieve in vivo competence

• Responses
• Clear evidence of increased availability and
  access
• Dont have to be expertsjust learn basics
• Organisational IT support
• Blended approach work-based activities / mentors
  and managers

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The role of e-learning Adding value simulation
and safe practice
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Course Structure(V. comprehensive but, in
manageable chunks)
Course map

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Interested?

• Contact Jo Wheeler, BTEC Co-ordinator
• Joanne.Wheeler_at_bromor-tr.wales.nhs.uk
• CADSG Assessment Centre
• Directorate of Learning Disability Services
• Glanrhyd Hospital
• Tondu road
• Bridgend
• CF31 4 LN
• Phone [phone]
• Time Around 120 hours to complete (21 hrs on
  line, 90 hrs off line)
• Money Total cost 150 per person
• Modest discounts depending on how many staff an
  organisation registers
• 2-10 staff 135
• 11-20 staff 127.50
• 20 staff 120
• Limited number of bursaries available for parents
  /unpaid carers

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Advanced Diploma in P B S

• 240 hours (45 online, 195 off line) costs 170-
  190
• 10 units
• Contemporary service values
• Person-Centred Planning
• Behavioural analysis
• Mental health and treatment options
• Primary prevention including Active Support
• Inclusive Communication
• Secondary prevention
• Reactive strategies
• How to construct a PBS plan
• Managing PBS, including goodness of fit, training
  carers, positive monitoring, monitoring
  effectiveness, troubleshooting and Periodic
  Service Review.
• Accreditation
• BTEC/Edexel, - nationally recognised
  qualification.
• mapped against NHS Knowledge and Skills
  Framework.
• National Occupational Standards
• Operationalise the guidance in the Mansell Report
  (revised edition, 2007) and comply with National
  Minimum Standards.

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Some other PBS e-learning sample activities