Sussex Partnership NHS Trust Positive Behavioural Support for

Sussex Partnership NHS Trust Positive Behavioural Support for People with Learning Disabilities who present Challenging Behaviour Dr Peter Baker Consultant Clinical Psychologist/Honorary Senior Lecturer Sussex Partnership NHS Trust / Tizard Centre University of Kent

Why focus on challenging behaviour? zfinancial cost

Need and capability in services for people with Intellectual Disabilities CAPABILITY OF SERVICE TO RESPOND INDIVIDUAL DEMAND ON SERVICE RANGE OF SERVICE PROVISION

Creating capable environments CAPABILITY OF SERVICE TO RESPOND INDIVIDUAL DEMAND ON SERVICE RANGE OF SERVICE PROVISION

Why focus on challenging behaviour? zfinancial cost y 31% of all people with learning disabilities placed out of area (DOH 2004)

Why focus on challenging behaviour? zfinancial cost zhuman cost yabuse yinappropriate treatment xpsychotropic medication xrestraints/protective devices xdegrading abusive psychological treatments yexclusion, deprivation & neglect zchallenges the comprehensiveness of community care

Positive Behavioural Support for People with Learning Disabilities who present Challenging Behaviour z. Traditional Behavioural Approaches z. Positive Behavioural Support • • • Influences Definition Characteristics Evidence Base Barriers to implementation

Early Behavioural Model Behaviour

Early treatment strategies z. Differential reinforcement schedules: reinforcement of other behaviours or low rate of behaviour. z. Extinction: non-presentation of a reinforcer. z. Punishment: ytype I application of an aversive stimulus ytype II removal of a positive stimulus

Punishment based strategies z z z Time out (Mace et al. , 1986) Visual screening (Lutzker, 1978) Verbal reprimand (Schutz et al. , 1978) Response satiation (Realon &Konarski, 1993) Overcorrection (Foxx & Azrin, 1973) Response interruption & manual restraint (Azrin et al. , 1988) Required relaxation (Foxx & Bechtel, 1983) Mechanical restraint & protective clothing (Dorsey et al, 1982) Water mist (Dorsey et al. , 1980) Aromatic ammonia (Tanner & Zeiler, 1975) Electric shock (Linscheid et al. 1990) Aversive tastes (Hogg, 1982).

Positive Behavioural Support z. Human Rights Agenda z. Deinstitutionalisation z. Functional Assessment

Functional Assessment Antecedents Behaviour Consequences

Functional Assessment Challenging Behaviour

Functional Assessment Environmental Factors Lack of choice Inadequate teaching strategies Minimal access to engaging materials Poorly selected daily routines etc Challenging Behaviour

Functional Assessment Environmental Factors Lack of choice Inadequate teaching strategies Minimal access to engaging materials Poorly selected daily routines etc Individual Factors Behaviour repertoire deficits -Communication skills -Self-management skills -Social skills -Self-help skills Physical health Mental heath Challenging Behaviour

Positive Behavioural Support z ‘…characterised by educational, proactive, and respectful interventions that involve teaching alternative skills to problem behaviours and changing problematic environments. It blends best practices in behavioural technology, educational methods, and ecological systems change with person-centered values in order to achieve outcomes that are meaningful to the individual and to his or her family’ Bambara et al (2004)

Positive Behavioural Support z. Is values led (in that the goal of behavioural strategies is to achieve community presence, enhanced choice, improved personal competence, greater respect and community participation, rather than simply behavioural change in isolation)

Positive Behavioural Support z. Is based on understanding of why, when and how behaviours happen and what purposes they serve (via the use of functional assessment)

Positive Behavioural Support z. Focuses on altering triggers for behaviour (in order to reduce the likelihood of the behaviour occurring) y. Stimulus based interventions x. Interspersal training x. Expansion of choice x. Curricular modification x. Manipulation of setting events

Positive Behavioural Support z. Uses skill teaching as a central intervention (as deficiencies in adaptive skills are often key contributing factors in behavioural challenges) y. Reinforcement based interventions x. Functional Communication Training x. Self Management

Positive Behavioural Support z. Uses changes in quality of life as both an intervention and outcome measure

Positive Behavioural Support z. Has a long-term focus (in that challenging behaviours are often of a long-term nature and successful interventions need to be maintained over prolonged periods)

Positive Behavioural Support z. Has a multi-component focus (reflecting that the fact that challenging behaviours are often multiply determined and also that users typically display multiple forms)

Positive Behavioural Support z. Reduces or eliminates the use of punishment approaches)

Positive Behavioural Support z. Includes both proactive strategies for changing behaviour and reactive strategies for managing behaviour when it occurs (because even the most effective change strategies may not completely eliminate risk behaviours from behavioural repertoires) Allen et al. (2005)

The Time-Intensity Model of Aggressive Incidents The physiological, emotional & physical path Early Intervention Reactive Management Post-crisis Intervention Prevention Baseline Trigger Escalation Crisis Kaplan & Wheeler (1983) Remorse & Recovery Baseline

Positive Behavioural Support z. At the present time, PBS approaches would therefore appear to offer the most ethically stringent, evidence-based intervention option for people with learning disabilities and challenging needs. As such, PBS may be said to represent a socially valid intervention approach. Allen et al. (2005)

Positive Behavioural Support z. UK research shows that only 2 -20% of people in need of such interventions actually receive any kind of behavioural support Oliver et al, 1987; Harris & Russell, 1987; Qureshi, 1994

z 50 -60% of people with learning disabilities who challenge will be in receipt of psychotropic (typically anti-psychotic) medication Kiernan et al, 1995; Fleming et al, 1996

Cochrane Review z‘It is debatable whether use of antipsychotic medication for certain people with a learning disability and challenging behaviour is ethical outside of a randomised control trial Brylewski & Duggan, 1999

z 50% or more will be regularly restrained Emerson (2002)

The Rhetoric Gap z. What works best is used least and what works least is used most

Possible Explanations z. Lack of PBS trained staff z. Cost z. Prejudice

Useful Reading z. Allen et al (2005) Positive Behavioural Support: Definitions, Current Status and Future Directions. Learning Disability Review, 10, 2, 4 -11. z. Baker & Shepard (2005) The Rebranding of behavioural Approaches for People with Learning Disabilities & Challenging Behaviour. Learning Disability Review, 10, 2, 12 -15.