The use of 'Positive Greetings at the Door' to increase on-task behaviour in a vocational training centre

Background : Preliminary studies suggest ‘Positive Greetings at the Door’ is a simple, low cost, antecedent intervention, for promoting engagement and reducing the risk of disruptive behaviour at the beginning of lessons. Method and materials : Three single case ABAB reversal designs were used in a vocational training centre for adults with intellectual disabilities. Real time duration recording was used to measure on-task behaviour. Interval recording was used to investigate staff delivery of verbal attention. Functional assessments of off-task behaviour were completed. Results : Results revealed that staff greetings produced increases in on-task behaviour, during the first ten minutes, from a mean of 54% during baseline to a mean of 79% during intervention phases. Staff greetings appear to set the occasion for staff to interact more frequently with participants. Conclusions : ‘Positive Greetings at the Door’ may be an antecedent manipulation that is low cost, technically undemanding, function-independent and effective in improving on-task behaviour

Outcomes from a community‐based Positive Behavioural Support team for children and adults with developmental disabilities

Background: Previous evaluations of community PBS teams have not investigated whether behaviour change is both statistically reliable and clinically significant. Few previous studies have reported quality of life (QoL) and social validity outcomes. Method: The present authors collected data on 85 people referred to a specialist PBS team. The present authors used a unique set of multiple measures and statistical change metrics to evaluate outcome. Results: Statistically significant improvements in QoL and health‐related QoL (HRQoL), with medium to large effect sizes, were demonstrated following PBS input. Mean Behaviour Problems Inventory‐Short Form scores reduced from 37.74 (SD = 30.54) at baseline to 12.12 (SD = 12.24) at follow‐up, with a large effect size (d = 0.84). Stakeholders reported valuing the process and outcomes of PBS, findings which support the social validity of PBS for people with developmental disabilities. Conclusion: This study demonstrates successful PBS outcomes in QoL, HRQoL, challenging behaviour and social validity in a community setting

Positive behavioural support for adults with intellectual disabilities and behaviour that challenges: an initial exploration of the economic case

Background: Since the closure of long-stay hospitals, positive behavioural support and person centred approaches have been recognised and encouraged to support people with intellectual disabilities in the community. Method and materials: A small before-after study was conducted to explore the economic case for a positive behavioural support service for five adults with intellectual disabilities and behaviour that challenges in a small local authority in England. Evidence from a Delphi exercise was used as comparator. Results: The service was effective in improving the outcomes (behaviours that challenge, activity engagement, community participation) at a total cost of services of £2,296 per week. By maintaining persons with less severe challenges in the community (£9 to £164 per week) and those with more severe behavioural needs in less service-intensive residential accommodations (£1,213 to £3,696 per week), the service may potentially reduce public services cost in the long term. Conclusions: The positive behavioural support service may have the potential to improve outcomes and lower cost of care in the long term

Effectiveness of active support for adults with intellectual disability in residential settings : systematic review and meta-analysis

Background The review examined the effectiveness of Active Support (RQ1) and stakeholders’ experiences of the model (RQ2). Method Data were meta-analysed (RQ1; Studies=14) and synthesised narratively (RQ2; Studies=10). Results By follow-up (six-months post-training), effect sizes (RQ1) for resident total activity engagement were significant and ranged from small (d=0.33, 95% CIs: 0.10, 0.50) to large (Tau-U=0.95, 95% CIs: 0.64, 1.25) depending on study design. Follow-up changes in staff assistance were moderate (d=0.56, 95% CIs: 0.23, 0.89; Tau-U 0.63, 95% CIs: 0.32 to 0.93) and large for quality of support (d=1.03, 95% CIs: 0.61, 1.44). Other outcomes did not change. Conclusions Active Support was more effective following complete staff training, in larger settings, at lower staff-to-resident ratios, and with less experienced staff. Active Support training and outcomes were valued by staff and residents (RQ2), and staff experienced increased job satisfaction. Lower staff turnover and organisational readiness appear crucial for maintaining implementation

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

Implementing evidence-based practice: the challenge of delivering what works for people with learning disabilities at risk of behaviours that challenge

There is an apparent disconnect between the understanding of best practice and service delivery in the support of people with learning disabilities at risk of behaviours that challenge. We suggest, is a problem of implementation. The purpose of this paper is to explore reasons why this might be the case: a failure to recognise the collective works of successive generations of research and practice; and a failure to address the macro-systems involved and systems changes needed to support implementation. Design/methodology/approach: This paper reviews the consensus that exists in respect of best practice. Drawing upon ideas from implementation science the paper highlights the complexities involved in the implementation of all evidence-based practices and uses this as a framework to propose ways in which an infrastructure that facilitates the delivery of services in the learning disabilities field might be built. Findings: This paper highlights core recommended practices that have been consistent over time and across sources and identifies the systems involved in the implementation process. This paper demonstrates that many of the necessary building blocks of implementation already exist and suggests areas that are yet to be addressed. Critically, the paper highlights the importance of, and the part that all systems need to play in the process. Originality/value: In the absence of any generalised implementation frameworks of evidence-based practice in the learning disabilities field, the paper suggests that the findings may provide the basis for understanding how the gap that exists between best practice and service delivery in the support of people with a learning disability at risk of behaviours that challenge might be closed

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 person's 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

Active support

This chapter provides an overview of Active Support, an approach developed in the UK for persons with severe or profound intellectual disabilities living in small community homes who rely on staff support to engage in the ordinary activities of everyday life. The chapter begins with a description of the development and subsequent evolution of working methods into an integrated system of Active Support. The focus throughout is upon creating and sustaining opportunities for engagement by people with intellectual disabilities in a broad range of everyday activities and interactions. Next there is an overview of the characteristics of two main approaches that currently exist for delivering Active Support, and the similarities and differences between them. This overview should enhance the reader’s understanding of the processes and outcome expectations that define the approach, and increase his or her knowledge of how training is designed and delivered. The next section of the chapter reviews and then updates research on Active Support following the publication of two major narrative reviews published in 2008. This section updates research on Active Support and Active Support training and identifies future directions for researchers working in the field. Finally, the concluding section considers practice issues that commonly arise when services begin to think about implementing Active Support, and identifies possible strategies for overcoming or avoiding some of the challenges they may face

Interactive training for active support : perspectives from staff

Background: In this study, we describe the experience of participating in interactive training (IT) for active support (AS). Staff (N = 58) working with adults with an intellectual disability (ID) received IT on providing effective assistance for participation in daily activities. Method: Semi-structured interviews were conducted with staff (N = 37) on their experience of IT, the way it affected their work, and their views on the implementation of AS. Results: High levels of satisfaction with IT were reported. Most staff identified at least one skill learnt during IT that they were still using 8 months later. No clear and consistent picture of AS implementation emerged across the service; staff identified a number of barriers, with lack of managerial support as the most significant. Conclusions: Interactive training can directly affect staff behaviour and has the advantage of being positively perceived by staff. However IT alone cannot ensure successful AS implementation, which is affected by a number of other factors, such as managerial support and input, residents' challenging behaviours, and staffing levels

Can brief workshop interventions change care staff understanding of challenging behaviours?

Background: The working culture surrounding challenging behaviour may have a strong effect on staff behaviour. As a first step to influencing staff talk about challenging behaviour, the aim of the present study was to explore whether a 1-day training workshop could have an effect on staff causal explanations. Methods: Fifty-four front line staff, in six separate groups, completed an adapted version of the Self-Injury Behavioural Understanding Questionnaire (SIBUQ; Oliver et al. 1996) both before and after a 1-day training workshop. The workshops were based on principles of Applied Behaviour Analysis. The SIBUQ comprised questions about causes of challenging behaviours presented in 11 short scenarios. The four possible response options for each scenario reflected behaviourally correct, behaviourally incorrect, internal emotional, and internal organic causal explanations. Results: The number of correct behavioural causal hypotheses increased significantly from pre- to post-training. The proportion of incorrect causal explanations that were behavioural in orientation also increased significantly from pre- to post-training. Conclusions: Staff causal explanations for challenging behaviour can be changed using a relatively brief intervention. Further research is needed to establish whether such changes can be used to influence working culture in challenging behaviour services