Supporting people through challenges

November 2013 Dublin

Symposium

Developing proactive person-centred

support

Dr Edwin Jones
Service Development Consultant
Directorate of Learning Disability Services
 The basics
 Need to know people well
 Work out why the need to use Challenging
Behaviour to get what they want
 Find better ways of helping them to get
what they need—that are more effective
than their challenging behaviour
 Improve quality of life!
 The Term ‗Challenging Behaviour‘
‗Ymddygiad Heriol‘
A social definition - behavioural problems are an
interaction between
1. Personal characteristics – e.g. severity of Intellectual
disabilities, ability to communicate, presence of secondary
disabilities , behavioural phenotypes etc
2. Environmental factors- e.g. levels of stimulation,
aversive stimuli, overcrowding, heat, staff interaction

Locates the problem not as internal to the

individual—but in this interaction—
The ‗challenge‘ is for us to provide the best
environments
 Good
Practice Leadership
Multi-disciplinary support
Training work-related skills
Positive Behavioural
Support
Person-centred
•Function of CB
•Proactive focus -Primary
Prevention
•Active Support
•Reactive strategies
•Clear Plans
Staff Supervision
Frequent staff meetings
Quality Assurance system
Stress management
How good a  Bad
service is will
Administrative ‗management‘
affect how
Limited external support
“challenging” a
person is Very little relevant training
No clear approach
Staff-orientated
No clear plans
Reactive focus rather than
prevention
Restraint- ‗fire fighting‘
Service users spend most time
doing nothing
Self Injury No staff supervision
Physical Aggression Infrequent staff meetings
Other inappropriate No Quality Assurance
behaviour Stressed staff
 A Vicious Circle In Hotel Models
Staff do most things for
service users, they react to
CB by using restraint /
seclusion/ sedation

Staff think reactively Service users use

& use punishment to CB to control the
control CB. ‘domestic environment—they
worker / security do not participate
guard’- Role-Keep the and spend most
house clean and no one time doing nothing
gets hurt too badly’

Staff perceive service users

as dangerous, dependent &
unable, they do not interact
with or assist service users
 The ‗in their shoes‘ test
One way of checking on the
acceptability of an Intervention
is to apply the ‘in their shoes’
test:

 This test asks a very simple

question – would you like
this intervention done to
you?

 If the answer is ‘No’, then

the intervention fails this
test of social validity.
 The ‗supermarket‘ test
 A second test of social validity is
called the ‘Supermarket’ or
‘Sainsbury’s’ test.

 Historically, many intrusive, aversive

behavioural interventions were
conducted in institutional or clinic
settings.

 Our aim today is to provide support

for all people with learning
disabilities in community settings.

 The ‘supermarket’ test asks us

whether we would be able to carry
out a particular intervention in
public.
 VALUE-BASED OUTCOMES
 the right to a lifestyle valued by society
 being part of a community
 having a network of relationships; family and friends
 having continuity in relationships
 having opportunities to develop experience &
competence
 be as independent as possible
 having choices, control & to be involved in decisions
which affect ones life
 be given status, respect & treated as an individual
 Positive Behavioural Support
Cymorth Ymddygiad Cadarnhaol
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
Behaviour Function & Environments
(Toogood & McGill-1994)

Get away
(Escape or
Avoidance)

Increase social contact

(attention)

Adjust sensory stimulation

(sensory)

Get something
(tangible)
Behaviour Function Unhelpful environment
(Toogood & McGill-
1994)
Get away Aversive situations
(Escape or e.g. Complex demands
Avoidance)

Increase social contact Low levels of social contact

(attention) mainly contingent on CB

Adjust sensory Under or over stimulating

stimulation environments
(sensory)
Get something Limited access to preferred
(tangible) objects/activities
Behaviour Unhelpful Provide Helpful McGill &
Toogood
Function environment environments 1994

Escape or Aversive situations Remove, reduce & manage

Avoidance e.g. Complex aversives e.g. Provide more
demands support and assistance

Increase social Low levels of High levels of social contact,

contact social contact mainly contingent on
(attention) mainly contingent adaptive behaviour
on CB
Adjust sensory Under or over Typical places with
stimulation stimulating meaningful activities or
environments calmer places still with
typical things to do
Get preferred Limited access to Materials and activities which
things preferred are readily and predictably
objects/activities available
 Changing person‘s physical environment
Primary Altering programmatic environment

prevention Introducing total communication

Addressing internal setting events (mental & physical health)
Improving carer confidence & competence
Eliminating or modifying specific triggers for behaviour
Increasing rates of access to preferred reinforcers
Increasing the density of social contact
Increasing rates of engagement
Modifying demands
Providing additional help
Embedding
Building behavioural momentum
Teaching general skills
Teaching functionally equivalent skills
Teaching coping skills

Stimulus change
Secondary Stimulus removal

prevention Coping skills

Not ignoring
Strategic capitulation
Diversion to reinforcing activities
Diversion to compelling activities

Proxemics
Reactive Self-protective

strategies Minimal ‗Ethical‘ Restraint

 BTEC accredited PBS
e learning qualifications
for more info contact Joanne.Wheeler@wales.nhs.uk
Course title Target Key content Hours on/ Cost per
audience off line candidate
Advanced Direct Knowledge and 30 on line £220
certificate in support skills re PBS 140 off line
PBS staff strategies
Advanced Managers As above + 45 on line £420
diploma in How to manage the 195 off line
PBS implementation of
‘practice PBS
leaders!’

Advanced As above +++ 80 on line £800

professional Behavioural How to conduct a 280 off line
diploma specialists full Functional
analysis and write a
PBS plan
 Practice Leadership
―coaching, directing, role-modelling,
supervising, and supporting. House
supervisors‘ practice needs to be
competent and it must be seen by direct
support staff. Practice leaders need to
actively, consciously and deliberately make
clear to support staff what they should do
and how they should do it‖ (Clements and
Bigby ,2007)
Dr Edwin Jones, Abertawe Bro
Morgannwg University NHS Trust
/ University of Glamorgan 15
 Some ides of what could help
develop practice leadership
 Training managers in
PBS
 Positive monitoring
 Interactive training
 Clarifying managers
roles-hands on, Integrate
Establish
supervisory PBS throughout
proactive
 Clear JD‘s Organisation &
practice leadership
management
 Time for managers to culture
manage system
 Scope- how many staff
/ teams

16
Dr Edwin Jones, Abertawe Bro Morgannwg University NHS Trust / University of Glamorgan
 Effective training strategies
A combination 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)

3-In Vivo accurately and reliably

perform the skills in the
workplace or real environment
2-Role play demonstrate what to do under
simulated conditions
1-Verbal tell you what they should do
 1. The Different Levels Of Assistance
Do you ASK- INSTRUCT- PROMPT- SHOW- GUIDE
want to
make a
cup of
tea >>>>>>>>>>>>>>> >>>>>>
level of help increases
2. Thinking In Steps
Breaking things down into steps & doing one step at a time

3. Reinforcing Participation
Paying attention to service users when they are actively participating and
maximising naturally occurring rewards

18
 Interactive Training
 Takes place in the service user‘s home.
 A trainer works with one member of staff at a time.
 The trainer observes the member of staff working
with a service user doing activities.
 The trainer feeds back to the member of staff and
they both suggest ways of increasing the service
user‘s participation.
 The member of staff tries out suggestions
 The trainer feeds back etc.

19
 Positive Monitoring
 Managers observe staff -frequently and
systematically
 Provide specific feedback to individual staff
members –to motivate them!!!
 Provide general feedback to the whole staff
team
 Can show you when you need to provide
more support to staff & or change PBS plans
 Develop a PM Observation Checklist from
the PBS plan—to help do this
 Helpful Environments: Virtuous Circle
Staff 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 Service users

proactively and participate
creatively – successfully in
improving some activities.
interaction and Q of L improves
communication. CB decreases
Staff see
themselves as
enablers
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
Go raibh maith agat
Diolch
Thankyou
Edwin.Jones@wales.nhs.uk