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ABM Ymddiriedolaeth Prifysgol GIG Abertawe Bro Morgannwg University NHS Trust. ARC branch meeting Challenging Behaviour & Positive Behavioural Support. Dr. Edwin Jones. People with learning disabilities and challenging behaviour.

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Arc branch meeting challenging behaviour positive behavioural support l.jpg

ABM

Ymddiriedolaeth Prifysgol GIG

Abertawe Bro Morgannwg

University NHS Trust

ARC branch meetingChallenging Behaviour & Positive Behavioural Support

Dr. Edwin Jones


People with learning disabilities and challenging behaviour l.jpg
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 will…influence the number of people defined as presenting a serious challenge. Well organised and managed services…will show fewer problems’ (Mansell Report, 1993)


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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


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‘Investment is required to achieve two aims: skills-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


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Mapping study (SPT, 2004) skills

  • 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) skills

  • ‘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 skills

  • 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


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Criticisms of SRV/ Normalisation skills

  • 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


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AIMS skills(service accomplishments)O’Brien (1987)

  • Community presence

  • Choice

  • Competence

  • Respect

  • Participation


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Applied Behaviour Analysis skills

  • 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


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Criticisms of ABA skills

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

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 are themselves morally blind. Like a stout sword, they work equally well in the hands of hero or tyrant’ (Wood, 1983)

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? are themselves morally blind. Like a stout sword, they work equally well in the hands of hero or tyrant’ (Wood, 1983)

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

  • 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


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Access to Behavioural Support in UK are themselves morally blind. Like a stout sword, they work equally well in the hands of hero or tyrant’ (Wood, 1983)

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


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Training Effectiveness: SPT PBS Training are themselves morally blind. Like a stout sword, they work equally well in the hands of hero or tyrant’ (Wood, 1983)(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 are themselves morally blind. Like a stout sword, they work equally well in the hands of hero or tyrant’ (Wood, 1983)

‘ …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


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Our response: No easy answers are themselves morally blind. Like a stout sword, they work equally well in the hands of hero or tyrant’ (Wood, 1983)

Remind

  • effective training

    Explain

  • why e learning

    Show

  • content

    Tell

  • how to access


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Human Services are themselves morally blind. Like a stout sword, they work equally well in the hands of hero or tyrant’ (Wood, 1983)

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)


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Traditional Approaches to Training are ineffective are themselves morally blind. Like a stout sword, they work equally well in the hands of hero or tyrant’ (Wood, 1983)

  • ‘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 are themselves morally blind. Like a stout sword, they work equally well in the hands of hero or tyrant’ (Wood, 1983)

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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Advanced/specialist level are themselves morally blind. Like a stout sword, they work equally well in the hands of hero or tyrant’ (Wood, 1983)

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


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Contemporary services are themselves morally blind. Like a stout sword, they work equally well in the hands of hero or tyrant’ (Wood, 1983)

  • 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 are themselves morally blind. Like a stout sword, they work equally well in the hands of hero or tyrant’ (Wood, 1983) but, it’s not a panacea!


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Dispersed geographical area are themselves morally blind. Like a stout sword, they work equally well in the hands of hero or tyrant’ (Wood, 1983)

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


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And there’s more …….. are themselves morally blind. Like a stout sword, they work equally well in the hands of hero or tyrant’ (Wood, 1983)

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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Challenges are themselves morally blind. Like a stout sword, they work equally well in the hands of hero or tyrant’ (Wood, 1983)

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


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The role of e-learning are themselves morally blind. Like a stout sword, they work equally well in the hands of hero or tyrant’ (Wood, 1983)Adding value – simulation and safe practice


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Course map are themselves morally blind. Like a stout sword, they work equally well in the hands of hero or tyrant’ (Wood, 1983)

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


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Interested? are themselves morally blind. Like a stout sword, they work equally well in the hands of hero or tyrant’ (Wood, 1983)

Contact: Jo Wheeler, BTEC Co-ordinator

[email protected]

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


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Advanced Diploma in P B S are themselves morally blind. Like a stout sword, they work equally well in the hands of hero or tyrant’ (Wood, 1983)

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 are themselves morally blind. Like a stout sword, they work equally well in the hands of hero or tyrant’ (Wood, 1983)sample activities


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