Ealing ITSBS: Preventing Residential Placements for Young People with Learning Disabilities and Challenging Behaviours. Dr Catherine Sholl & Dr Caroline Reid, Clinical Psychologists, Ealing CAMHS/Ealing Services for Children with Additional Needs (ESCAN). ITSBS. In partnership with. ITSBS.
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Dr Catherine Sholl & Dr Caroline Reid, Clinical Psychologists, Ealing CAMHS/Ealing Services for Children with Additional Needs (ESCAN)
In partnership with
What is ITSBS?
ITSBS = Intensive Therapeutic and Short Breaks Service
Based within Ealing Services for Children with Additional Needs (ESCAN) - multi-agency.
Collaborative initiative between Clinical Psychology, Social Services and Short Breaks Services for children with disabilities.
Aims to enable young people with a Learning Disability and challenging behaviour to remain within their family and community settings.
Provides intensive support including an extended short break and intensive clinical psychology input with the young person, family and
Policy and Legislative Background
Importance of preventing residential placements and enabling people with LD to remain in their family and community settings:
Aiming High for Disabled Children (2007)
Valuing People: A Strategy for Learning Disability for the 21st Century
Mansell report revised (2007)
Between 5 and 15% of people with a learning disability present with challenging behaviours whereby the safety of them or others is compromised (Borthwick-Duffy, 1994; Quereshi & Alborz, 1992)
Once young people go into residential placements they tend to remain in them as adults (from clinical experience) & Mansell (2007)
Risks of residential care – Winterbourne View
Background to ITSBS
Key partners involved
Key components of the ITSBS model:
Psychological models of working
Demographics of cases seen Oct 08-April 12
16 cases seen during this period:
14 were male, 2 were female
Mean age was 12-13 years (range from 8-17 years)
Ethnicity – 7 Asian British, 4 mixed race British, 3 black African, 1 White British/Irish, 1 White British
9 living in single parent families and 7 living with both parents
13 young people had siblings, 3 did not
3 of the young people had a sibling with a diagnosis of ASD.
All 16 young people seen had a diagnosis of Moderate/Severe Learning Disability
14/16 of the young people also had a diagnosis of ASD
5/16 of the young people had a diagnosis of Epilepsy
All cases were referred due to high levels of challenging behaviour at home and in other settings (e.g. school, short break services)
All 16 cases, families/other professionals were concerned about home placement breakdown
14/16 cases already accessing a range of
short break services and professional support
A typical referral
Typical process for intervention
Detailed psychology assessment and analysis of the challenging behaviours at home, school, and in short breaks setting – quantitative measures (DBC with parents, carers and school, parents 3 concerns, and carer satisfaction scales pre & post intervention), discussions and meetings with the family and relevant professionals, observations in various settings, functional analysis of challenging behaviours, building relationship with the network, child and family.
Formulation developed to identify the underlying reasons and consequences for the challenging behaviours and shared with family and carers - PPPP.
Extended Short Break
Young person may have an extended short break at the short break service for a period of 3 weeks
Prepared for this using social stories, and countdown provided during the stay
At the beginning of the stay clinical psychology develop a behaviour management plan (following on from assessment and formulation)
Short breaks staff are trained to implement positive behavioural strategies, and the family visit to observe and practice this
Clinical psychology visit regularly to monitor and support implementation of the plan and offer staff consultation
If a break away from the home is not appropriate then an intensive package may be offered with carers in the family home/community and consultation from clinical psychology.
Intervention may include:
Extended/intensive short breaks
Positive behavioural support plan for managing challenging behaviour
Work on reducing and managing anxiety/rituals/obsessions
Work on building child and family’s mood and confidence, and re-building positive relationship between family and child
Work on sleep difficulties
Family work in community settings
Family work reflecting on experience of caring for a child with complex needs, impact on family relationships, siblings, etc.
Systemic family therapy
Liaison and joint sessions with SaLT, OT, Ed Psych
Liaison with psychiatry/paediatrics re medical issues and medication (e.g. epilepsy, melatonin, mental health medications)
Regular consultation and network meetings with all carers and professionals involved.
Service outcomes so far...
16 families offered the service Oct 2009-April 2012
Pre and post data collected so far N=11
For 15/16 young people seen between 2008 and 2012 residential placement has been prevented at this time and quality of life reported to have improved for families.
For 1 young person residential placement was not prevented. Factors involved included him already being in part-time residential placement, late referral, housing eviction, parental mental health difficulties. However, he has since left residential and returned to the family home.
Pre and Post Intervention Measures
1. Developmental Behaviour Checklist (DBC-P; Achenback, 2002) - 96 item instrument for assessing emotional and behavioural difficulties in children with learning disabilities - 5 subscales; i) Disruptive/Anti-Social, ii) Self-Absorbed, iii) Communication Disturbance, iv) Anxiety and v) Social Relating, and provides an overall Total Behaviour Problem Score.
2. Three Concerns - asks those involved with the young person what their top three concerns are and asks them to rate how worried they are about each concern.
Measures Post Intervention only
“It has helped me to find positive solutions to my child’s problems…and made me look at my son’s problems in a different way. I no longer feel at the mercy of his temper and he doesn’t feel the need to lash out because he knows I’m on his side and I’m trying my best to understand him.”
“The way the psychologist looked into every aspect of our child’s difficulties and worked out plans to help with each one, and getting other agencies involved e.g. short breaks, OT and SaLT. She was very pro-active in helping us e.g. doing home visits and going out in the community with our child.”
Example cost comparisons (09-10)
Approx costs per year 2010 onwards
0.8 clinical psychologist £37 301
Full time assistant psychologist £32 036
8 extended short break packages £40 000
(costs have ranged from £3694-£5022 per child)
This £109 337 aims to provide intensive work to 6-7 families and follow up work to previous families (if needed)
This service cost is less than the minimum cost of just 1 residential placement for 1 year.
Advantages of ITSBS: What makes it successful?
The break gives the family a break from the norm and time to:
sleep and recover
think about their child and their wishes for their future
attend Clinical Psychology appointments
consider new ways of supporting their child
re-organise the home and make changes to the environment.
Intensive Clinical Psychology input means that it is possible to gain a thorough understanding of one young person, their family and the challenging behaviour they present, across a variety of settings, and develop and implement an individualised behaviour plan to promote consistent responses and strategies across settings.
Clinical Psychology input also gives the parents, young person and siblings a place to reflect and think about their feelings
and relationships with one another and the impact of
caring for a child with a disability.
Challenges and Reflections
Timing of different agencies and multi-disciplinary working
Working with VERY large networks
Holding responsibility for most complex cases
Managing risk to staff and families
Staff burnout – importance of consultation, supervision and informal support
Skilling up staff – training and consultation role of psychologists as well as therapeutic work
Motivation of families
Shifting culture/attitudes around residential placements
Restrictions around physical resources e.g. space in schools, housing, financial
1. Links with the Tizard Centre:
2. Continue to increase menu of short breaks approaches utilised by this service and evaluate.
3. Development of the approach to include Mild LD and High Functioning ASD.
Conclusions and Recommendations
The evidence obtained so far indicates this model should be considered as a viable local and cost-effective option for young people presenting with severe challenging behaviours whose home placements are at risk of breaking down.
Positive feedback from families who have received this service.
Costings indicate that although this service does require additional staff resources and financial support, this is considerably less than the cost of residential placements.
Children with learning disabilities and their families have a right to receive the local support that they need to help their child continue to live and participate in their community settings, while also experiencing a decent quality of life, and this service promotes these values and makes this possible for families who are in considerable need.
Publications in press
Sholl, Reid & Udwin (in press). Preventing residential care for young people with intellectual disabilities and challenging behaviour: The development of the Ealing Intensive Therapeutic and Short Breaks Service. Association for Child & Adolescent Mental Health Special Issue.
Reid, Sholl & Gore (in press). Preventing residential care for young people with intellectual disabilities and challenging behaviour: Emerging data from the Ealing Intensive Therapeutic and Short Break Service.TizardLearning Disability Review.
Dr Catherine Sholl and Dr Caroline Reid
Ealing Services for Children with Additional Needs
21-22 The Mall
Tel: 020 8825 8744 or 020 8825 5429