CONFERENCE CONFERENCE

Wednesday 26th June 2013Wednesday 26th June 2013BristolBristol

Dr Edwin Jones & Professor Kathy LoweDr Edwin Jones & Professor Kathy Lowe

Service Development ConsultantsService Development Consultants

Directorate of Learning Disability ServicesDirectorate of Learning Disability Services

Active Support as a Primary Prevention Strategy for

Challenging Behaviour

22

1. The Different Levels Of AssistanceASK- INSTRUCT- PROMPT- SHOW- GUIDE

>>>>>>>>>>>>>>>>>>>>>

2. Thinking In StepsBreaking things down into steps & doing one step at a time

 

3. Reinforcing ParticipationPaying attention to service users when they are actively participating

and maximising naturally occurring rewards

level of help increases

Do you want to make a cup of

tea

Active Support (Jones et al. 1999)Active Support (Jones et al. 1999)

Around for over 30 yrs had to be reintroduced in 1999 Around for over 30 yrs had to be reintroduced in 1999 despite it’s proven effectivenessdespite it’s proven effectiveness

Strong evidence that Active Support (AS) very Strong evidence that Active Support (AS) very effective in improving quality of life of PWLD by effective in improving quality of life of PWLD by improving staff interaction and planningimproving staff interaction and planning

Some indications that those with the highest support Some indications that those with the highest support needs benefit most and that interactive training and needs benefit most and that interactive training and practice leadership are key componentspractice leadership are key components

(Felce et al 1986, 2002a, 2000b, Jones et al 1999, 2001b, Mansell et al (Felce et al 1986, 2002a, 2000b, Jones et al 1999, 2001b, Mansell et al 2003, 2008, Stancliffe et al, 2007; 2008; 2010 Toogood 2008, Totsika et al 2003, 2008, Stancliffe et al, 2007; 2008; 2010 Toogood 2008, Totsika et al 2008b Beadle-Brown 2012;)2008b Beadle-Brown 2012;)

Positive Behavioural Support (PBS)A Definition

Values based, person centred technology

Understanding why a person has challenging behaviour

Changing the environment, reducing the need for challenging behaviour

Respecting and including the person

Improving the skills and quality of life of the person and those around them

Keeping people safe

Tried and tested

AS & PBSAS & PBS Similar origins in Applied behaviour Similar origins in Applied behaviour

Analysis & Social Role ValorisationAnalysis & Social Role Valorisation Non aversive- no punishment or Non aversive- no punishment or Primary Prevention= Improving Primary Prevention= Improving

environment so people get what they need environment so people get what they need without having to use Challenging without having to use Challenging behaviourbehaviour

Key concept- improvements in quality of Key concept- improvements in quality of life lead to reductions in CBlife lead to reductions in CB

AS & CBAS & CB Little focused research on AS & CBLittle focused research on AS & CB

Methodological issuesMethodological issues Direct Observation (e.g. MTS)--Highlights Direct Observation (e.g. MTS)--Highlights

high frequency “minor(?)” CB e.g. stereotypyhigh frequency “minor(?)” CB e.g. stereotypy Staff reports –highlights low frequency high Staff reports –highlights low frequency high

impact ‘major’ CB e.g. aggression & impact ‘major’ CB e.g. aggression & destructiondestruction

Most AS studies to date have used direct Most AS studies to date have used direct observationobservation

Direct obs studiesDirect obs studies

Jones et al 2001aJones et al 2001a Smith et al, 2002Smith et al, 2002 Mansell et al, 2001Mansell et al, 2001 Bradshaw et al, 2004Bradshaw et al, 2004

Research on AS and CB

Stancliffe et al, 2007; 2010 Koritsas et al, 2008 Beadle-Brown et al, 2012 Toogood et al, 2009, 2011

Current research

3 studies

(direct observation) Study 1 – secondary analysis

Systematic clinical data Study 2 – resettlement from hospital Study 3 – redevelopment of existing service

Study 1Study 1

5 well established supported living houses5 well established supported living houses Total of 19 participants Total of 19 participants Selected to represent people with Selected to represent people with

profound to severe learning disabilitiesprofound to severe learning disabilities Only house 1 had no participants with CBOnly house 1 had no participants with CB

House 1

0

20

40

60

80

100

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

timepoints

%

challenging behaviour engagement

House 2

0

10

20

30

40

50

60

70

80

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

timepoints

%

challenging behaviour engagement

House 3

0

10

20

30

40

50

60

70

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

timepoints

%

challenging behaviour engagement

House 4

0

20

40

60

80

100

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

timepoints

%

challenging behaviour engagement

House 5

01020304050607080

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

timepoints

%

challenging behaviour engagement

STUDY 2STUDY 2 Resettlement in North WalesResettlement in North Wales Active Support introducedActive Support introduced Functional analysis (NHS staff)Functional analysis (NHS staff) Behaviour management plans (secondary and Behaviour management plans (secondary and

reactive)reactive) Data from systematic clinical records Data from systematic clinical records

(incidents, participation, community use, as (incidents, participation, community use, as required meds)required meds)

4 service users – very serious behaviours4 service users – very serious behaviours

Service User A

0

200

400

600

800

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31

timepoints

Num

ber

CB incidents Participation

Service user B

050

100150200250300350400

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35

timepoints

Num

ber

CB incidents Participation

Service User C

0

100

200

300

400

500

600

1 3 5 7 9 11 13 15 17 19 21 23

timepoints

num

ber

CB incidents Participation

Service User D

0

100

200

300

400

500

600

1 3 5 7 9 11 13 15 17 19 21 23 25

timepoints

num

ber

CB incidents Participation

Study 3Study 3 Major redevelopment (NAS) – 4 yearsMajor redevelopment (NAS) – 4 years 19 service users19 service users New operational proceduresNew operational procedures Active Support, Studio 3Active Support, Studio 3 Baseline – 2005, Post data – 2010Baseline – 2005, Post data – 2010 Measures – ABS, ABC, incidents, community Measures – ABS, ABC, incidents, community

useuse 4 service users – high levels of cb at outset4 service users – high levels of cb at outset

Service User 1

0

5

10

15

20

25

30

35

years

nu

mb

er o

f in

cid

ents

Service User 2

01020304050607080

1 2 3 4

Years

Nu

mb

er o

f In

cid

ents

Service User 3

0

5

10

15

20

25

30

35

40

years

nu

mb

er o

f in

cid

ents

Service User 4

0

2

4

6

8

10

years

nu

mb

er o

f in

cid

ents

Summary of results

Different methodologies highlight different behaviours Observation – stereotypies Incident recording – other behaviours

Similar conclusion – AS led to reduced CB and increased engagement in activity

CB not eliminated - caution

AS as Primary PreventionBehaviour Behaviour FunctionFunction

Unhelpful Unhelpful environmentenvironment

Provide Helpful environmentsProvide Helpful environments

Get awayGet away

(Escape or(Escape or

Avoidance)Avoidance)

Aversive situationsAversive situations

e.g. Complex e.g. Complex demandsdemands

Remove, reduce & manage Remove, reduce & manage aversives e.g. Provide more aversives e.g. Provide more support and assistancesupport and assistance

Increase social Increase social contactcontact

(attention)(attention)

Low levels of social Low levels of social contact mainly contact mainly contingent on CBcontingent on CB

High levels of social contact, High levels of social contact, mainly contingent on adaptive mainly contingent on adaptive behaviourbehaviour

Adjust sensory Adjust sensory stimulationstimulation

(sensory)(sensory)

Under or over Under or over stimulating stimulating environmentsenvironments

Typical places with meaningful Typical places with meaningful activities or calmer places still activities or calmer places still with typical things to do with typical things to do

Get something Get something

(tangible)(tangible)

Limited access to Limited access to preferred preferred objects/activitiesobjects/activities

Materials and activities which Materials and activities which are readily and predictably are readily and predictably availableavailable

Other Factors include

Severity of learning disability Inactivity Lack of structure/predictability of activity Mental health issues Poor health

AS helps achieve least AS helps achieve least restrictive environmentsrestrictive environments

Padlocks on fridges are a very stark image of a restrictive practice and a custodial prison like environment

Restrictive practices, are unethical, aversive and can act as setting conditions or triggers for challenging behaviour (service user D)

Active Support provided the technology to remove the locks from the fridge enabling safe unrestricted access to food his desired tangible removing the main trigger for CB

Active Support can act as a powerful cultural change agent—changing staff attitude by proving alternative practice can work

A Vicious Circle In Hotel ModelsA Vicious Circle In Hotel ModelsStaff do most things for service users, they react to CB by using restraint / seclusion/ sedation

Staff think reactively & use punishment to control CB. ‘domestic worker / security guard’- Role-Keep the house clean and no one gets hurt too badly’

Service users use CB to control the environment—they do not participate and spend most time doing nothing

Staff perceive service users as dangerous, dependent & unable, they do not interact with or assist service users

Primary Primary preventionprevention

Changing person’s physical environmentChanging person’s physical environmentAltering programmatic environmentAltering programmatic environmentIntroducing total communicationIntroducing total communicationAddressing internal setting events (mental & physical health)Addressing internal setting events (mental & physical health)Improving carer confidence & competenceImproving carer confidence & competenceEliminating or modifying specific triggers for behaviourEliminating or modifying specific triggers for behaviourIncreasing rates of access to preferred reinforcersIncreasing rates of access to preferred reinforcersIncreasing the density of social contactIncreasing the density of social contactIncreasing rates of engagementIncreasing rates of engagementModifying demandsModifying demandsProviding additional helpProviding additional helpEmbeddingEmbeddingBuilding behavioural momentumBuilding behavioural momentumTeaching general skillsTeaching general skillsTeaching functionally equivalent skillsTeaching functionally equivalent skillsTeaching coping skillsTeaching coping skills

Secondary Secondary preventionprevention

Stimulus changeStimulus changeStimulus removalStimulus removalCoping skillsCoping skillsNot ignoringNot ignoringStrategic capitulationStrategic capitulationDiversion to reinforcing activitiesDiversion to reinforcing activitiesDiversion to compelling activitiesDiversion to compelling activities

Reactive Reactive strategiesstrategies

ProxemicsProxemicsSelf-protectiveSelf-protectiveMinimal ‘Ethical’ RestraintMinimal ‘Ethical’ Restraint

Helpful Environments: Virtuous CircleHelpful Environments: Virtuous CircleStaff provide opportunities and assistance for service users to participate. This helps to prevent CB. If CB does occur they respond positively-rather than punish

Staff think proactively and creatively –improving interaction and communication. Staff see themselves as enablers

Service users participate successfully in some activities. Q of L improves CB decreases

Staff perceive service users as less dangerous & more competent. Staff give service users more respect, control & attention. Staff feel more confident, successful & eager to try new things

DiolchDiolchThank YouThank You

Edwin.Jones@wales.nhs.uk Kathy.lowe@wales.nhs.uk

Jones, E., Lowe, K., Brown, S., Albert, A., Saunders, C., Haake, N & Leigh, H. (2013). Active Support as a primary prevention strategy for challenging behaviour. International Journal of Positive Behavioural Support, 3 (1), 16-30.

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