ARC branch meeting Challenging Behaviour & Positive Behavioural Support

1. ABM Ymddiriedolaeth Prifysgol GIG Abertawe Bro Morgannwg University NHS Trust ARC branch meetingChallenging Behaviour & Positive Behavioural Support Dr. Edwin Jones

2. 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

3. 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 will…influence the number of people defined as presenting a serious challenge. Well organised and managed services…will show fewer problems’ (Mansell Report, 1993)

4. Induction & refresher practical training in work-related skills Practice Leadership Multi-disciplinary 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-orientated 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

5. ‘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) Mansell II

6. 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

7. 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

8. 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 person’s disability and the need to change these

9. Criticisms of SRV/ Normalisation • Advocates an intervention strategy that lacks a scientific base:‘The 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

10. AIMS (service accomplishments)O’Brien (1987) • Community presence • Choice • Competence • Respect • Participation

11. 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 time…appears 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

12. 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

13. ‘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)

14. 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

15. Positive Behavioural Support Applied Behaviour Analysis (Science) PCP (Philosophy & framework) Normalisation/ SRV (Philosophy) + + = Positive Behavioural Support:A values-led toolkit for behaviour change

16. 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

17. A PBS Model • Primary Prevention: changing aspects of a person’s 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 Strategies:ethical responses to risk behaviours that maximise the safety of both service users and carers

18. Access to Behavioural Support in UK • Rates of use of behaviour change strategies, restraint & medication for challenging behaviours

19. 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

20. Our Challenge ‘ …the competence or capability of local ‘mainstream services for people with learning disabilities will…influence the number of people defined as presenting a serious challenge. Well organised and managed services…will 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

21. Our response: No easy answers Remind • effective training Explain • why e learning Show • content Tell • how to access

22. Human Services Most staff • Don’t have formal qualifications • Don’t 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)

23. 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)

24. 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)

25. 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 levels of training 3 Adv Prof Diploma NVQ 4/5 2 Prof Diploma NVQ 3/4 1 Adv Certificate NVQ 2/3

26. 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

27. E learning can meet many contemporary service needs but, it’s not a panacea!

28. 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 Benefits/ advantages of e learning

29. And there’s 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

30. 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 Don’t have to be experts—just learn basics Organisational IT support Blended approach work-based activities / mentors and managers Disadvantages/risks of e learning

31. The role of e-learning Adding value – simulation and safe practice

32. Course map Course Structure(V. comprehensive but, in manageable chunks)

33. Interested? Contact: Jo Wheeler, BTEC Co-ordinator Joanne.Wheeler@bromor-tr.wales.nhs.uk CADSG Assessment Centre Directorate of Learning Disability Services Glanrhyd Hospital Tondu road Bridgend CF31 4 LN Phone 01656 753849 • 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

34. 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.

35. Some other PBS e-learning sample activities