Transcript Non aversive approaches

Developing Crisis Support Plans Using Low Arousal
Approaches..
Andy McDonnell, PhD,
Director, Studio3 Training Systems,
WWW.studio3.org
Challenging Behaviour
A definition
‘Culturally abnormal behaviour of such
intensity, frequency or duration that the
physical safety of the person or others is likely
to be placed in serious jeopardy, or behaviour
that is likely to seriously limit the use of, or
result in the person being denied access to
ordinary community facilities.’
Emerson 1995
Non aversive approaches
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Early behavioural interventions concentrated on the
consequences of behaviour.
 The use of punishing consequences to suppress
behaviour has been extremely controversial.
 In many ways we attempt to control what we fear.
 In the last two decades there has been an increasing
emphasis on intervening before a challenging
behaviour occurs.
 Many of these approaches can be labelled as positive
behavioural supports.
Autism
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People with autistic spectrum disorders
(ASD) can present behaviours that
challenge and a recent survey of the
behavioural intervention literature
identified a diagnosis of autism as a risk
marker for physical aggression
(McClintock, Hall and Oliver, 2003).
Aggression
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These behaviours may furthermore
result in injury to clients when attempts
are made to restrain them and thus may
provoke physical abuse from carers
(Rusch, Hall & Griffin, 1986).
Crisis Management is Important
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Carr et al. (1994) maintained that crisis
interventions are needed and that “it is a
mistake to think that once an intervention
is underway, you no longer need to
worry about serious outbursts and the
necessity for crisis management” (Carr
et al. 1994, p.14).
Crisis management Research is
Needed!
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A large number of behavioural
intervention studies have tended to focus
on long term interventions for physical
aggression (Horner, Carr, Strain, Todd
and Reed, 2000) with short term
management receiving less attention
(McDonnell, 2006).
Aggressive Behaviour:
Often emerges in early childhood and
persists over decades.
 Is functional and adaptive
 Is about communication and control
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Causes of violence and
aggression in persons with an
ASD
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Communication difficulties
Confusion
Unexpected change – breaking a routine or ritual
Environmental factors – heat, overcrowding, noise, etc.
Sensory differences i.e. hyper and hyposensitivity
Pain or medical problems
Medication changes
Inactivity/boredom
Demands and requests
Emotional problems and mental illness
Too many rules and restrictions
Being denied a need or getting something that they don’t want
PEOPLE!!
Cognitive Behavioural
Approaches
THOUGHTS
FEELINGS
BEHAVIOUR
Testing Our Assumptions about
Behaviour
Aware
In Control
Not in
Control
Not Aware
What is arousal?
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Arousal is a construct which is
notoriously difficult to define with
researchers adopting views that it is
either a unitary or multifaceted construct;
recent research in neurobiology indicates
that there is a generalised arousal
mechanism in the brain which feeds
cortical functions (Pfaff, 2006).
Negative effects of high arousal
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The construct of arousal is considered
useful in understanding the regulation of
emotion (Pfaff, 2005) and arousal and
stress are considered to be important in
the moderation of emotions (Reich and
Zautra, 2002).
Arousal and ASD
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There is some laboratory evidence of
differences in physiological responses of
individuals with ASD compared to non
autistic controls (Althaus, van Roon,
Mulder, Mulder, Aarnoudse and
Minderaa 2004; Hirstein Iversen and
Ramachandran 2001; van Engeland,
Roelofs, Verbaten and Slangen, 1991)
Sensory difficulties in ASD
Increasing interest in this area.
 ‘some autistic individuals cannot tolerate
food of some particular taste, smell,
texture and appearance (certain colours
for example) or even the sound it
produces when they chew it’
(Bogdashina, 2003, p63).
 Sensory difficulties are vital to
understand if staff are to develop
behaviour management strategies.
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Sensory difficulties
Processing using one modality.
 Inconsistency in visual perception.
 Sensory agnosia (difficulties interpreting
a sense).
 Delayed processing.
 Sensory overload: Remember this can
be a painful physical experience for
some people.
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Maintaining Equilibrium: A central
tenet.
A balance between internal and external
stimuli is required to maintain levels of
arousal.
Equilibrium/balance
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The human body has a sensitive self-monitoring and
self-regulating system that is constantly working to
maintain the body in homeostasis (balance).
I would suggest that physiological arousal employs a
similar mechanism. A balance is struck between
internal and external sources of arousal. Let us call it
arousal homeostasis.
Each individual has an optimum performance
threshold of arousal to functioning successfully.
We are aiming for a state of arousal equilibrium.
Regulation of arousal is problematic for some people
with ASD.
Maintaining equilibrium
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Stereotyped movements may help maintain
equilibrium because they serve a de-arousing
function.
 Rituals may occur more frequently when
arousal levels increase.
 People avoid specific arousing stimuli.
 Other do individuals seek out arousing stimuli.
Arousal and Stress
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Stress and anxiety have been proposed as
factors in challenging behaviours of people
with ASD (Howlin, 1998; Groden, Cautela,
Prince and Berryman, 1994). Lazarus and
Folkman (1984) described a transactional
model of stress emphasizing interaction
between an individual and his/her
environment. Stress occurs when the
demands of stressors outweigh coping
responses and there is a clear interaction
between environmental and physiological
events.
Aggressive behaviour and panic
reactions
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Many people with ASD and challenging behaviours
show signs of panic in specific situations.
Behaviours may be interpreted as deliberate by carers
in these situations
Similarities have been drawn between the symptoms
of post traumatic stress disorder and some individuals
who present with challenging behaviours (Pitonyak,
2004).
Panic reactions can often lead to people needing to
escape from situations.
Panic responses do not appear to habituate rapidly.
This may be true of a specific subset of people with
ASD.
Low arousal approaches in practice
A key component of these approaches to
behaviour management is REFLECTIVE
PRACTICE.
 A carer may often be making a situation
worse accidentally
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What makes you
angry?
How do you
express your
anger?
How do you cope?
How do you Destress?
Definition
" attempts to alter staff behaviour by
avoiding confrontational situations and
seeking the least line of resistance."
 (McDonnell, Reeves, Johnson & Lane,
1998, p164)
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Low Arousal
Theoretical Assumptions
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ASSUMPTION ONE
Most people who are challenging are usually extremely aroused
at the time. We should therefore avoid doing anything that will
arouse a person who is already upset.
ASSUMPTION TWO
A large proportion of challenging behaviours are usually preceded
by demands and requests, therefore reducing these should help
to reduce the frequency and perhaps the intensity of the
incidents.
ASSUMPTION THREE
Most communication is predominantly non-verbal, therefore we
should be aware of the signals we communicate to people who
are upset.
Symptoms of physiological arousal
In anxiety disorders arousal is increased
in response to a ‘perceived threat’.
 Rapid beating heart.
 Sweaty hands and other forms of
perspiration.
 Pupils may increase in size.
 Panic reactions (including escape from
situations).
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Anatomy of an Incident
CRISIS
Arousal
Level
Triggering Phase
‘Normal’ range
Time
Non verbal behaviours
Eye contact: Should be avoided when a
person is angry.
 Touch: Keep this to a minimum.
 Interpersonal space: We are much more
aware of the space around us when we
are angry or aroused.
 Postures: Threatening postures need to
be avoided.
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Non verbal behaviours
Language: language needs to be clear
and simple, avoid ritualistic debates.
 Avoid key trigger phrases such as ‘calm
down’
 Do attempt to appear calm and give off a
minimal amount of energy.
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Developing a crisis plan
John is a 23 year old man with
intellectual disabilities and autism.
 His repetative questioning of staff was
considered to be a major problem.
 John was reported to be really
dangerous.
 Verbally aggressive behaviours
occurred on a daily basis.
 Physical aggression at least weekly.
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An Observation
Analysis
Staff member is ignoring the person.
 John is very stressed.
 His arousal level is so high that cannot
process what the staff member is saying
to him.
 He is asking ‘Who is on later’ and not
getting the answer he NEEDS to hear.
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Individualised training
The staff team had a one day training
course which focussed on low arousal
approaches.
 John’s support plan was reviewed.
 Many staff felt that John ‘did things on
purpose.
 We made them understand that he was
frightened and scared.
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Individualised Training
We selected practical examples of
everyday situations that led to physical
aggression.
 Strategies to distract John (tea and
coffee worked well).
 Visual aids used
 Staff practiced a new approach using
role play methods.
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After training
Outcomes
There was no incidents of physical
aggression for 6 months.
 Staff reported that John seemed a lot
calmer.
 Staff reported that they felt calmer.
 One staff member felt that things had
worked but they were ‘Giving In’.
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Longer term arousal regulation
Relaxation techniques.
 Sensory environments.
 Physical exercise.
 Sensory diets.
 Environmental design.
 Antecedent control.
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Conclusions
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Sensitivity to arousal as a model of working
has several implications.
 We are aiming to create ‘arousal equilibrium’
for individuals.
 Assessment of individual arousal sensitivity
should be a fundamental part of the approach.
 Pharmacological approaches may need to
concentrate more on reducing or in some
cases increasing physiological arousal.
Conclusions
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Designing environments where arousal levels
can be controlled (heat, light, colour, space,
sounds).
 Developing more self control distraction
strategies (wearing walkmans, use of mood
music).
 Anxiety reduction strategies may help some
individuals (see Attwood, 2006).
 Consider individual arousal responses when
developing individualised activity plans.
Conclusions
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The behaviour of staff has significant impact
on the management of challenging
behaviours.
 Staff may inadvertently trigger challenging
behaviours (McDonnell, 2005)
 Training staff/families to recognise the initial
signs of panic and sensitivity may have a
significant effect.
 Short term demand reduction should be a
major facet of crisis management for people
with ASD/Intellectual disabilities.
Who needs to Change?
"Things do not
change, we
change." (Henry
David Thoreau)