Applied behaviour analysis used

in an NHS ward for people with

dementia: Clinical examples

Emma Williams, Rebecka Rornes, Choo Ying Lau, Dr Carolien Lamers, & Dr Rebecca Sharp (BCBA-D)

Person Centred Working in Dementia Care: All Wales Forum

12th October 2017, Enlli Conference Centre, Aberystwyth

Overview

Collaborative practicum training with health board

Dementia ward

Specific environmental considerations (e.g., temporary

setting for clients)

Introducing ABA to a new setting

Examples of specific behaviour change projects from interns

What is applied behaviour analysis?

= application of principles of behaviour to improve the lives of people

growing interest and evidence that can be used to improve quality of life of people with dementia, established evidence for ID

is person-centered, tailored to individuals’ needs, collaborative (i.e., programmes are designed and implemented with the input of families and people in the environment)

3

We seek functional relations

= A lawful relation between values of two variables.

Analytic: The study should demonstrate convincingly that the behaviour change was due to the intervention and not confounding variables I.e., the study should demonstrate a functional relation between

manipulated events & behaviour of interest (cf. internal validity)

Behaviour change was due to intervention / environmental changes

We do this with small-N design

Functions of behaviour

1. Social positive reinforcement (to obtain something

appetitive)

2. Social negative reinforcement (to avoid / remove

something aversive)

3. Automatic reinforcement (stimulatory)

Reinforcers can be mediated by another person (1 and 2) or by the

individual (3).

Reinforcers & behaviours can also be private events (thoughts & feelings).

Behavioural approaches

Teach new skills

Decreasing behaviours that challenge

Maintaining / preserving skills and

independence

Staff and caregiver

training6

Facilitating independence

Example 1:

Mealtime intervention to

maintain independence

An overview of how self-feeding skills could be maintained in a

busy hospital environment

Hospital settings can reduce independent skills

(Burgio & Burgio, 1990)

Staff under time constraints

High turnover of staff and patients, meaning BST not always

effective (Stryker, 1981)

Untrained staff

Care staff undertake 90% of daily living tasks (Crawford et al,

1983)

Intervention aim: To reduce staff feeding patients unnecessarily

Mealtime assessment

Task analysis of fork food, spoon food, and finger food

Direct observation and prompting hierarchy used

Intervention: Placemat

o Information on

placemat based on

assessment results

o Placemat SD for staff

o SD = like a signpost

for behaviour

Results

To make and evaluate

placemats for all those who

require them

Continue to assess the

effectiveness

Example 2:

Choice and food

A simple intervention to increase the amount of food intake

Background

Choice can be a powerful antecedent (i.e., can

increase engagement with tasks)

Examples from literature – people with TBI or LD

(choice increased likelihood would complete

household tasks, found it was the act of having a

choice, not doing nicer tasks) (Tasky et al., 2008)

Method

New client to ward (female)

Low food consumption, staff concerned about

declining weight

History of rich variety of food

Not given choice at tea time

Method

Put selection of each

sandwich type on tray

Showed (visual prompt),

verbally labelled each

sandwich

Asked to choose which

type she wanted

Place choice on small

plate

Repeat until client stated

enough on plate

Asked if would like a

biscuit too (one choice)

Number of bites per

session recorded (20

min sessions)

Bite’ operationally-

defined

Results

Discussion

Withdrawal design used to show experimental control

Simple provision of choice increased food

consumption

Next steps are :

train staff to implement

generalise to other meals

add information to medical file to ensure maintenance

Quality of life

Example 1:

Name badges

Evaluation of intervention to support client use of staff names

Name badges

Effects of verbal prompt (name badge) on the

frequency of name calling behaviour

Written prompts can promote performance

(Cuvo et al., 1992), not much dementia

research though

Replicates the name badges design

introduced by Northern Lincolnshire and

Goole NHS Foundation Trust (2014) in their

#hellomynameis campaign

Socially valid – interns asked to evaluate

Design

ABAB design: Baseline Intervention Withdrawal Intervention

Two recording methods:

Observation by interns (20 min session, partial interval recording 10 s)

Self-report by staff (per shift – 12 hours)

Record frequency of name calling behaviour:

Calling the correct name

Calling the wrong name

Calling the generic titles and other (i.e. “hey, you” etc.)

Results - direct observation

Results – staff report

Discussion

Both observation and self-report from staff reported the similar

results - an increase in name calling of the correct name (effective

antecedent intervention)

The use of name badge did not reduce calling generic title –

perhaps some clients do not have textual verbal operant (i.e.,

can’t read)

Possible extensions – different prompts for people who don’t have

textuals, check accuracy of self-report, social validity for staff and

clients (i.e., do they like it)

Example 2:

Family-style dining

Behavioural differences between individual and group meals

Background

Dependency promoting environment in nursing

Independent feeding as an operant behaviour

Prompting and praise

Kayser-Jones (1996) and mealtime atmosphere

Increasing communication & participation through Family style

dining (Altus, Engelman & Mathews, 2002)

Method

3 clients (one man, two women)

Able to verbalise (to different degrees) and eat

independently (i.e., feeding assessment)

Setting and time of day

Communication, Participation, Engagement

Results

Discussion

Successfully increased engagement, participation, and

communication (depending on client skills) but all socially

significant

Graphs to be used to show management team, and to

arrange a family-style meal once per week

ABAB withdrawal to be used to show experimental control

Example 3:

Interactions between clients

Increasing meaningful engagement

Background

Difficulties manipulating physical environment on ward due to strict safety

guidelines

Replicated Gallagher & Keenan’s (2000) study where the residents

participated in a specially-designed activity

Vocal behaviour sub-codes of The Staff Resident Interaction Chronograph

(Paul & Lentz, 1977):

Meaningful interaction: one resident engaged in conversation with another resident by

asking a question, making a comment, statement or joke

Conversation: a single interaction (e.g., question, single word, discussion or debate)

Response: the other party listening, maintained eye contact, nodding etc.

Method

Two females with vocal verbal behaviour,

mobile

Recording method: 20 min sessions of

momentary time sampling (10-s), recorded

resident-to-resident interaction

Intervention: intern sat with one client and

asked other “Would you like to sit with us?”

Results

Discussion

Both were able to engage in conversation without any formal

activity

One client needed to use the bathroom during two sessions,

but returned and continued conversation unprompted

Planned next phase: to provide an activity to further help

conversation (e.g., preparing materials or discussion for

upcoming activity)

Teach staff to pair up clients – especially useful when staff are

occupied with other duties

Example 4:

Check-in procedure for attention-

maintained behaviour

An intervention to increase social interactions and decrease

behaviour of concern

Female client with dementia

Calling out to staff on average every 2.4 min

Staffing levels can make providing enough

attention difficult

Check in procedure identified for intervention

(Engstrom, Mudford, & Brand, 2015)

Background

Method

Direct observations to collect data on frequency of

calling for staff

Social validity for project, from staff and client point

of view.

Withdrawal design to assess effectiveness of

procedure

Increased client interaction opportunities

Results

Discussion

To increase check-in time in small increments to

make the intervention easily applicable in busy ward

environment

To provide client with increased interaction

opportunities, pairing up with other patients?

Follow-up with report to new residence to inform

care staff

Considerations

Evidence-based practice (combination of best research

evidence with clinical needs and needs of setting)

Simple but carefully evaluated interventions have been

effective

More complex work can be conducted (e.g., functional

analyses)

Growing interest in behavioural approaches – how can

we best disseminate?

Questions?

Thank you for

listening

r.a.sharp@bangor.ac.uk