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REACHING OUT
Providing Supports for People with Behaviours that Challenge
Gillian MartinThe Callan Institute for Positive Behaviour Support,
St. John of God Hospitaller Services
www.callaninstitute.org
Institute of Applied Behaviour Analysis
www.iaba.com Anne Donnellan, Gary LaVigna & Tom
Willis (Donnellan et al, 1988) Recent International conference (2005)
included representation from in the UK, USA, Tasmania, Greece, Canada, Ireland, Finland & Australia.
Assessment & Functional Analysis
Support system
•Speed & degree of effects •Generalisation •Maintenance •Quality of life•Side effects
Multi-element Behavioural support
Proactive Strategies
Skills Teaching
•General skills•Functionally equivalent skills•Functionally related skills•Coping & tolerance skills
Direct Intervention
•Reward no behaviour•Reward low rates of behaviour•Reward alternatives•Co-operation training•Satiation
Environmental Accommodations
•Setting•Interactions•Activities•Choice•Variety
•Ignore•Redirect•Feedback•Instruction•Facilitate•Stimulus Change•Active Listening•Crisis Intervention
Reactive Strategies
Outcomes
Robert
Proactive StrategiesProactive Strategies Reactive StrategiesReactive Strategies
I’m confused!What’s happening next?
Too noisy!I can’t wait!
Tralee
Dundalk
Celbridge
Residential servicesResidential servicesGroup homesGroup homesDay centresDay centresSpecial schoolsSpecial schoolsAdult training & Adult training &
Work enterprisesWork enterprises = = 3,0003,000 people people
Dublin
Dun Laoghaire
Bray
Drogheda
Drumcar
Hospitaller Order of St John of God
BelfastIslandbridge
Examples of St. John of God Services:
Job Coaching / Employment Residential Placement Mental Health / Dual Diagnosis Services Day Services Respite Services Schools (early intervention and secondary) Outreach Services
Geographical Dispertion of Service Users with Intellectual Disability (SJOG) N=2943
Belfast0%
Dublin54%
Louth21%
Kildare17%
Tralee8%
Staff
No of Staff employed in Intellectual Disability Services = 1661
Includes Employment Specialists Nursing Staff Clinical Staff Social Care Staff Teachers, Classroom Assistants & SNA’s
Coverage
“The widespread adoption and consistent implementation of positive behavioural support could significantly improve the quality of life of many people with severe intellectual disabilities and severe challenging behaviour. To achieve this constitutes, perhaps, the single greatest challenge for this area of applied behaviour analysis.” (Emerson, 2001)
Approx 840 with behaviour that limits their access to community facilities
Approx 450 people with very severe challenging behaviours (tissue damage in the last 3 months)
Service Users w ith Behaviours that lim it their access to
com munity
ID
Behaviour Limits accessto community (28%)
Service Users with Severe Challenging Behaviour
ID
Severe Challenging Behaviour(15%)
St. John Of God Services: 2,943 people with an Intellectual Ddisability
Traditional Models of Response to Behaviours that
Challenge Specialist Units
Discharge is difficult as resources are location specific
Associated with:Higher rates of injury to service usersLower rates of community activityGreater use of psychotropic medicationHigher costs (Robertson et al, 2002)
Traditional Models of Response to Behaviours that
Challenge Specialist Teams:
Can bring about reduction in behaviour in situ. Less intervention time Improvements in Quality of life Practical difficulties in coverage Contextual Fit is still weak as psychologists /
specialists are not on necessarily on site.
Contextual Fit
The congruence between behavioural support plan features and a set of variables that seriously affect the development and implementation and therefore effectiveness of those plans. (Albin et al, 1993)
Contextual Fit means
Support plan is highly compatible with values and skills of key stakeholders
Sustainable Unique to the individual and their environment Responsive to changes in situation Comfortable for people working with it More likely to result in long-term, effective
behaviour support.
Particular Case Training
Allows for greater contextual fit Direct Carers are more aware of environmental
features, knowledge of the person and of the behaviour. Staff learn to apply principles of applied behaviour
analysis Training is interspersed with practice in service setting
which allows for feedback Allows for training of a variety of staff and in a variety
of contexts
“Multi Element Behaviour Support: A Short Course”
9 month programme (64 hrs Contact; at least 100 hrs assignment & additional reading)
Competency based Accredited with Dublin Institute of
Technology (since 2001) CPD’s from Psychological Society of Ireland
(2004)
Course Outline
Module 1 (3 days) Assessment
Module 2 (1 day) Functional Analysis
Module 3 (1 day) Behaviour Support Plan
Module 4 (1 day) ¼ Report & Periodic
Service Review
Module 5 (1 day) Video
Module 6 (1 day) Final Portfolio
Features of MEBS: A Short Course
Practitioner Model of Learning (competency skills)
Tuition (written and verbal feedback) On the Job Demonstrations (local teams) Training in person-centred planning (John
O’Brien) Best Practice with quality assurance system
Course Materials
Lectures (given by principle clinical psychologist, behaviour specialists and invited guest speakers)
Lecture Workbook Assignment templates Post tests (5 units) Competency based assignments Technical support materials Tutor / Mentor Support Reading List Feedback & Supervision
Modes of Assessment
Post tests Pencil & Paper activities Role Play Demonstrations Verbal Presentations Written reports Video of field work Supervisor audit (application of competencies in
vivo)
Benefits of Particular Case Training
Kirkpatrick (1996) Levels of Learning
1. Trainee Satisfaction
2. Increased trainee knowledge
3. Measures on the job-performance change
4. Measures organisational results
Outcomes for the Organisation
Recognised body accredits training Reduced staff turnover as staff commit to
organisation for duration of training and beyond Training is in line with best practice Culture of Positive Behaviour Support is promoted Cost effective in relation to service provision,
training, response time and results
Outcomes for Participants
Staff earn credits for training completed Organisation is supportive in relation to
study time and mentoring Opportunities for promotion
Outcomes for Service User
Development of relationships with keyworker and circle of support
Outcomes including clinical, personal and social achievements.
Opportunity to develop self-advocacy skills.
Evaluation of Training
Review of outcomes for individual with behaviour that challenges
Review of staff competencies
Effectiveness for the organisation
Reduction of Behaviour
Sample of Status of Behaviour Relative to Baseline (n=93)
0%5%
10%15%20%25%30%35%40%45%50%
Behaviour Disimproved(increased by at least
30%)
Behaviour Unchanged(70% - 130% ofbaseline rate)
Moderate Improvement(Deceased by at least
30%)
Signif icantImprovement
(decreased by at least70%)
Status of Behaviour
% o
f Beh
avio
ur S
uppo
rt P
lans
Feedback from Participants (2005)
Relevance & Interest Ratings from Participants (n = 14)
0
10
20
30
40
50
60
1 2 3 4 5 6 7
Likert Scale 1 = not at all relevant / interesting to
7 = Very interesting or relevant
% R
esp
on
se
Relevance to work
Interest
Participant Results
020406080
100
%
1
Units
Breakdown of 2002 Logbook of Competencies (Total)
Introduction to Behavioural Support Environmental Accommodations
Skills Teaching Direct Interventions
Reactive Strategies Behavioural Assessment
Intervention Development
Number of SJOG Graduates2003-2004 (N=82)
Graduates by service users location
15
5
6
59
School
Mental Health
Supported Employment
Residential
Staff Training 2004
Course Number of courses Staff Trained
“A Short Course” 2 52
Introduction (1 day) 5 128
Intro (2&3 days) 3 258
Supervisors Workshop
2 13
Team Learning 1 9
Others (CPI, Systematic Instruction)
4 52
Total 15 511
Outcomes for Organisation
Course Advisory Board Evaluation Culture of Positive Behaviour Support Promotion to key managerial positions Promotion to positions outside of St. John of Gods Best Practice 440 (approx) staff trained / support plans implemented
(since 1995) Quality Assurance Recognition nationally and internationally through
European Credit Transfer System
Modes of Learning
Team Learning (approved 2003) Approval of Prior Learning (approved 2003) Applied Casework (in development) Academic Module (in development)
Development of Training Course
E-learning Train the facilitator Supervisor Support Use of external speakers Alignmement with Behaviour Analyst
Certification Board Presentation Skills
Academic Partnerships
Dublin Institute of Technology Limerick Institute of Technology Dundalk Institute of Technology Open Training College FETAC Post Graduate Course
Maintenance Study
Analysis of staff and organisational behaviour
Enhance staff training Enhance Management Practices Promote srategic planning
References I
Albin, R.W. et al (1999); Contextual Fit for behaviural support plans: A model for “Goodness of fit”. In Koegel, Koegel & Dunlap (1999) Positive Behaviour Support: Including People with Difficult Behaviour in the Community Baltimore, Paul Brookes Publishing
Dench, C. (2005); A Model for Training Staff in Positive Behaviour Support Learning Disability Review, Vol 10; Issue 2 pp.24 – 30. Pavilion Publishing Ltd, Brighton, UK.
Donnellan, A.M., LaVigna, G. W., Negri-Shoultz, N., & Fassbender, L.L. (1988) Progress without Punishment; Effective approaches for learners with behaviour problems. New York: Teachers College Press.
Emerson, E. (2001) Challenging Behaviour: Analysis and Intervention in People with Sevvere Disabilities Cambridge University Press, UK.
References II
Emerson, E. et al (1987) Developing Services for People with Severe Learning Disabilities and Challenging Behaviour. Canterbury, University of Kent
Hastings, R.P. (2005); Staff Training in Positive Behaviour Support; Research into Practice. Learning Disability Review, Vol 10; Issue 2 pp.31-33. Pavilion Publishing Ltd, Brighton, UK.
La Vigna, G.W. et al (1994) The Periodic Service Review. A Total Quality Assurance System for Human Services and Education. Baltimore: Paul Brookes Publishing
McClean, B; Dench, C; et al (2005) Person Focused Training: A Model for Delivering Positive Behaviour Supports to people with challenging behaviour. Journal of Intellectual Disability Research, Vol. 49 Part 5. Pp.340-352. Blackwell Publishing Ltd.
McClean, B. & Walsh, P (1995) Positive Programming – an organisational response to Challenging Behaviour. Positive Practices Vol. 1 pp.2-8