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

Multi Element Behaviour Support Model

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

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.

Effectiveness of Training

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

Future Developments

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

References III

Robertson, J et al (2002) Quality and costs of of community based supported accomodation for people with challenging behaviour. Paper presented at the International Association for the Scientific Study of Intellectual Disability, Dublin.