Transcript Staff Training for Challenging Behaviour: Evidence Based

Facing The Challenge
Dr. Ian Grey
KARE
Kilcullen
Co Kildare
Dr. Brian McClean,
Behaviour Support Service,
Brothers of Charity,
Roscommon
National Policy
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Treatment
Expert
Multi-disciplinary
Special unit
Challenging Behaviours
1. between 5 and 15 per cent of all
people with intellectual disabilities are
additionally challenged by behaviour
2. much higher rates in large residential
settings, where 3,440 Irish citizens live
3. higher rates in congregal settings
4. higher rates when people are
displaced from family and home
“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, p. 192).
Evidence of effectiveness:
Didden, R., Duker P.C, and Korzilius, H. (1997) Meta-analytic study on
treatment effectiveness for problem behaviours with individuals who
have mental retardation. American Journal on Mental Retardation.
10, 387-399
“prior functional analysis of challenging
behaviour correlates with a successful
intervention. The behavioural interventions
are much more effective than that
demonstrated by medication, for example”
Content analysis of functional hypotheses
12
10
8
Mean number
of plans
6
4
2
0
g
an
h
C
e
im
St
ul
n
io
t
a
s
n
m
st
io
is
e
s
c
u
it i
qu
nf
e
Cr
o
R
C
Negative Reinforcement
Hypotheses (77%)
P
n
so
r
e
te
At
n
io
t
n
as
Re
s
c
an
r
u
e
n
tio
c
fe
Af
l
ho
o
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Al
Positive Reinforcement
Hypotheses (23%)
• Five Exceptional People
– Severity criterion
– Placement Breakdown
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Medication
Psychiatric symptoms
Quality of life
Costs
Support systems
McClean, B., Grey, I. And McCracken, M. (2005) An Evaluation of Positive
Behavioural Support for People with Very Severe Challenging Behaviours in
Community-Based Settings. Paper submitted to the British Journal of Learning
Disabilities
50
Frequency of
physical aggression
% of 30 minute
intervals with
physical aggression
Aine
0
40
Andrew
20
0
400
Frequency of head
200
banging (bouts)
Sean
0
50
Frequency of
physical aggression
Ciara
0
Frequency of
physical aggression
2
1
0
Tom
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Months
50
Frequency of
physical aggression
10
Units of Medication
0
% of 30 minute
intervals with
physical aggression
Frequency of head
banging (bouts)
40
0
0.75
0.5
0.25
0
400
4
20
200
Units of Medication
Sean
10
Units of Medication
0
5
Ciara
0
2
1
2
Andrew
0
50
Frequency of
physical aggression
Aine
0
0
Frequency of
physical aggression
5
1
Units of Medication
0
0.5
0
Months
Tom
Baseline
20
10
0
Follow-up
(74 weeks)
Aine
Dep Anx Hyp
Mini PAS-ADD Scores
Intervention
(26 weeks)
Dep Anx Hyp
Dep Anx Hyp
20
10
0
Andrew
Dep Anx Hyp
Dep Anx Hyp
Dep Anx Hyp
20
10
0
Sean
Dep Anx Hyp
Dep Anx Hyp
Dep Anx Hyp
20
10
0
Ciara
Dep Anx Hyp
Dep Anx Hyp
Dep Anx Hyp
20
10
0
Tom
Dep Anx Hyp
Dep Anx Hyp
Dep Anx Hyp
Quality of Life Questionaire
QOL-Q Percentile Scores
Schalock et al, 1989
100
80
60
Pre
40
Post
20
0
Aine
Andrew
Sean
Ciara
Tom
Costs (in euro per annum)
Pre
Post
Ann
13,460
17,680
Andrew
80,000
83,600
Sean
165,000
165,000
Ciara
304,000
90,000
Tom
36,100
75,000
The Role of Family
50
F re q u en cy o f
p h ysica l a g g re ssio n
A in e
0
40
% o f 3 0 m in u te
in te rv a ls w ith
p h ysica l a g g re ssio n
20
A n d re w
0
400
F re q u en cy o f h e a d
b a ng in g (bo u ts)
200
Sean
0
50
F re q u en cy o f
p h ysica l a g g re ssio n
C ia ra
0
F re q u en cy o f
p h ysica l a g g re ssio n
2
1
0
Tom
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18
M o n th s
In summary
1. Flexible: Options in crisis
2. Responsive: Local
3. Individualised: Assessment and
costing
4. Skilled: Training
5. Real lifestyles: Family
Evidence Based Practice
• “the conscientious, explicit and judicious
use of current best evidence in making
decisions about the care of individual
people”
% of baseline behaviour
Evidence of effectiveness:
100
80
60
n=138
n=65
40
20
0
Baseline
1st Quarter
Follow-up
McClean, B., Dench, C., Grey, I., Shanahan, S., Fitzsimons, E., Hendler J., and
Corrigan, M. (2005) Person Focused Training: A model for delivering positive
behavioural supports to people with challenging behaviours Journal of
Intellectual Disability Research, 49, 340 - 352
Evidence of effectiveness:
Extremely Often (hourly)
Very Often (daily or more often)
Often (more than 4 times in month)
6
Frequency
5
4
Frequency Pre
Occasionally (1 to 4 times in month)
3
Frequency
Post
Not at all present
2
Never
1
Training
Control
Grey, I. and McClean B. (in press) Effectiveness of Person Focused Training: A
Control Group Study. Journal of Applied Research in Intellectual Disabilities
Inpatient Studies
• Very few studies
– Raitasuo (1999) Finland
– Xendititis (1999) UK
– Poole (2001) UK
Inpatient Studies 1
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Raitasuo (1999)
5 bed unit with 24 hour care (1.4 ratio)
40 admissions in 18 month period
Average stay 2.91 months
75% treated with anxiolytic
73% neuroleptic (35% diagnosis of psychosis)
No change for small moderate ID group
High re-admission rate (55%) within 6 months
Inpatient Studies 2
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Xenitidis (1999)
13 bed unit (mild-moderate with severe CB)
64 people over 10 year period
Reduction from .75 aggressive incidents per week
to .33 per week per person
• “treatment based on sequential hypothesis testing
and functional analysis”
• No details on medication
• No details on outcome after discharge
Inpatient Studies 3
• Rowland & Treece (2000)
• 7 clients with challenging behaviour &
autism presentation over 6 years
• No discharge over interval
• Emphasis on augmentative communication
• Reductions in use of anti-psychotics for 3 of
4 clients
Commonalities
• Data largely limited to mild ID
• Little good quality data with respect to
challenging behaviour
• Little evidence with regard to medication usage
and sedative effects
• Little evidence on challenging behaviour and
mental health post discharge but high re-admission
(50%) in some studies
• Evidence of ‘silting-up’
An additional E151 million per
annum
Could better outcomes
be achieved by
investing locally?