Sandy Toogood

Persistence of challenging behaviours in adults with intellectual disability over a period of 11 years

BACKGROUND Challenging behaviours in people with an intellectual disability (ID) often develop early and tend to persist throughout life. This study presents data on the chronicity of challenging behaviours in adults with ID over a period of 11 years, and explores the characteristics of people with persistent serious behaviour problems. METHOD Support staff provided data on 58 adults living in a long-term residential facility using an interview survey schedule assessing challenging behaviours in 1992 and 2003. RESULTS Participants presenting with serious physical attacks, self-injury and frequent stereotypy were the most likely to persist in these behaviours over time. These behaviours were characterised by high persistence percentages and associations over time. However, the earlier presence of serious challenging behaviours did not significantly affect the likelihood of serious challenging behaviours in 2003. Individuals with persisting behaviour problems differed from those who did not present serious behaviour problems on the basis of their younger age, increased mobility, and decreased sociability and daily living skills in 1992. CONCLUSIONS Estimates of persistence for challenging behaviours are affected by the statistics chosen to represent stability. The apparent persistence of serious challenging behaviours highlights the need to identify the factors related to maintenance of these behaviours over time. The participant characteristics and adaptive behaviours identified in the present study were not consistently related to the persistence of challenging behaviours. Therefore, other factors, including environmental characteristics, are likely to be related to challenging behaviour persistence.

Active Support: Development, Evidence Base, and Future Directions

Active Support is a person‐focused model of care for people with an intellectual disability who live in community‐based small homes. The model aims to improve each persons quality of life by maximizing participation in all types of activities of daily life with appropriate support from staff. In this chapter, we describe the basic characteristics of Active Support, its relationship with Normalization theory and Applied Behavior Analysis, and the evidence base for Active Support interventions. The methods available for training support staff and the latest developments in the Active Support model are presented. We conclude by discussing issues related to the adoption of Active Support by residential services and policymakers, and identifying dimensions that require further exploration. These future challenges include the translation of the Active Support model into real‐world settings and long‐term maintenance of intervention effects.

Organizing community placements

This chapter will first point to the ways in which placements for people with challenging behaviour often fail to deliver a satisfactory service. It will be argued that this failure is directly related to the occurrence and exacerbation of challenging behaviour. The characteristics of a more successful service will be described. The main part of the chapter will consider the ways in which services can organize themselves to produce such characteristics. Finally the chapter will consider the arguments often used against such an organizational technology and point to some of the requirements for successful implementation.

Staff behaviour and resident engagement before and after active support training

Abstract Background Identifying the factors associated with greater increases in resident engagement has the potential to enhance the effectiveness of active support (AS). Method Observational data from Stancliffe, Harman, Toogood, and McVillys (2007) study of AS were analysed to evaluate amount of staff help, effectiveness of staff help, and staff use of praise. Results Lag analyses showed that antecedent staff help was consistently followed by resident engagement at pre-test. This strong association did not increase significantly at post-test. Resident engagement was more likely to follow staff help than the other way around. There was an increase from pre-test to post-test in help and praise by staff. The higher absolute amount of praise was largely the result of the increase in staff help. Conclusions The amount of staff help, its effectiveness, and use of praise by staff may each be important in increasing engagement. These factors should continue to be the focus of research attention and applied efforts to help ensure active support is consistently effective.

Challenging behaviours in adults with an intellectual disability: A total population study and exploration of risk indices

OBJECTIVES Considerable variation has been reported in the prevalence and correlates of challenging behaviour (CB) in adults with intellectual disabilities (ID). To provide a robust estimate of prevalence, we identified the entire administrative population of adults with ID in a defined geographical area and used a behaviour assessment tool with good psychometric properties. METHODS Data from 265 adults who were known to services were collected using a demographic survey tool and the Behavior Problems Inventory - Short Form. The prevalence of self-injurious, aggressive/destructive, stereotyped, and overall CB was evaluated. We explored the potential of developing cumulative risk indices (CRI) to inform longitudinal research and clinical practice. RESULTS The prevalence of overall CB was 18.1% (95% CI: 13.94-23.19%). The prevalence of self-injurious behaviour was 7.5% (95% CI: 4.94-11.37%), aggressive-destructive behaviour 8.3% (95% CI: 5.54-12.25%), and stereotyped behaviour 10.9% (95% CI: 7.73-15.27%). Communication problems and severity of ID were consistently associated with higher risk of CBs. CRIs were significantly associated with CBs, and the five methods of CRI development produced similar results. CONCLUSIONS Findings suggest a multi-element response to CB is likely to be required that includes interventions for communication and daytime activity. Exploratory analyses of CRIs suggested these show promise as simple ways to capture cumulative risk in this population. Subject to longitudinal replication, such a tool may be especially useful in clinical practice to identify adults who are priority for interventions and predict future demand on services. PRACTITIONER POINTS The prevalence of challenging behaviour (CB) was 18.1% in this total population study. Stereotypy was the most frequent type of CB. Communication difficulties and severe-profound intellectual disabilities were most systematically related to the presence of CB. Establishing the effect of multiple risk factors is likely to identify people who are priority for interventions. Addressing multiple, rather than singular risks, is likely to be more efficacious. We tested five different methods of putting together a multiple risk index. All methods provided a reasonable association with CB. The most user-friendly method was the additive cumulative risk index (CRI). Limitations This is a cross-sectional design which enabled factors currently associated with CB to be identified for the whole cohort, but these variables may not be those conferring risk for the development or maintenance of CB over time. Future longitudinal research is required to replicate these CRI analyses before concluding about the CRI method with the highest predictive validity.

Prevalence of psychotropic medication use and association with challenging behaviour in adults with an intellectual disability. A total population study

BACKGROUND There is a high prevalence of psychotropic medication use in adults with Intellectual Disabilities (ID), often in the absence of psychiatric disorder, also associated with challenging behaviour. Previous research has focused on specific sample frames or data from primary care providers. There is also a lack of consistency in the definition of challenging behaviour used. METHODS We adopted a total population sampling method. Medication data on 265 adults with ID were classified according to the Anatomical Therapeutic Chemical classification system. The Behaviour Problems Inventory - short form classified challenging behaviours. We examined the association between challenging behaviour and the use of psychotropic medication, and whether any association would still be present after accounting for socio-demographic and clinical characteristics. RESULTS 70.57% of adults with ID were prescribed at least one class of any medication (mean per person =2.62; range 0-14). Psychotropic medications were used by 37.73% of participants with antipsychotics the commonest type used by 21.89% of individuals. Polypharmacy and high dosages were common. Generalised Linear Models indicated significant associations between psychotropic medication and the presence of a psychiatric diagnosis, challenging behaviour, older age and type of residence. Male gender was additionally associated with antipsychotic medication. CONCLUSIONS The use of a total population sample identified via multiple routes is less likely to overestimate prevalence rates of medication use. Current challenging behaviour was a predictor of medication use after controlling for other variables. Data indicate that there may be differences in prescribing patterns associated with different topographies of challenging behaviours.

Establishing a context to reduce challenging behaviour using procedures from active support: a clinical case example

Client engagement increases substantially when staff teams implement active support. The impact of active support on challenging behaviour is less clear. There are grounds for believing that active support procedures could in some cases neutralise environmental conditions known to evoke challenging behaviour. We implemented a three‐phase clinical intervention to increase engagement and reduce passive and challenging behaviour. In phase 1 we trained staff to deliver inviting activity‐based instruction at eye level. In phase 2 we introduced activity support plans to increase client choice and control. In phase 3 staff used peer‐monitoring procedures to consolidate implementation. We measured staff behaviour and client outcome across the three phases of intervention and at follow‐up. Staff provided warm and inviting activity‐based instruction at eye level more frequently after participating in phase 1 on‐site training. The proportion of activity‐based interactions with choice increased when activity plans were introduced in phase 2. Engagement replaced passive and challenging behaviour. Staff observations suggested changes were maintained over the short run. Our own observations indicated decay at 22 months. Our data suggest that active support procedures can make challenging behaviour less likely by altering antecedent conditions that reliably evoke such behaviour. Without sustained effort, interventions are susceptible to decay.

Staffing numbers and active support: a case study

Purpose – The purpose of this paper is to investigate the effect of staffing levels (one or two staff) on the amount of assistance provided to residents in one group home, and associated levels of resident engagement in activities prior to and following the implementation of active support.Design/methodology/approach – Data on staff assistance and resident engagement were gathered by direct observation across six pre‐test and post‐test 80‐minute sessions, using palmtop computers. Percentage of all non‐overlapping data, an index of effect size, was used to analyse these data.Findings – There was no clear benefit from additional staffing prior to active support training, in terms of staff assistance or resident engagement in activity. However, at post‐test, having two staff yielded increased staff assistance, but with limited evidence of increased resident engagement, despite more continuous staff assistance.Originality/value – This is the first active support study to examine the impact of staffing levels ...

Ten Years of Providing Intensive Support Services for People with Learning Disabilities and Challenging Behaviour: A Brief Service Description and Review

This article describes the development of a specialist peripatetic support service for people with learning disabilities whose behaviour is challenging. It addresses service goals, working methods and development objectives, reviews selected aspects of service process and client outcome, and comments on the impact of changing demand on the service environment.

Can active support improve job satisfaction

Purpose – Active support (AS) influences the way staff support people with intellectual disabilities to take part in everyday activities. Changes in work practices may affect job satisfaction. The impact of AS on job satisfaction has not, however, been widely studied. Job satisfaction is linked with levels of staff turnover and the overall quality of services provided to people with intellectual disabilities (Coomber & Barriball, 2007; Hatton et al., 2001). The purpose of this paper is to describe an evaluation of job satisfaction amongst 38 direct care staff working in intellectual disability services before and after AS was implemented. Design/methodology/approach – A single group, repeated-measures design was used. In total, 38 members of direct care staff received AS training. Data on job satisfaction were collected before, and after, AS was implemented. In total, 19 members of staff took part in a follow-up 12 weeks later. Findings – There was a significant increase in reported job satisfaction follo...