The information which follows is a real example of the work of Redstone PBS. The details have been changed and reduced to preserve confidentiality. The aim of this and other similar posts is show how positive behaviour support can be implemented to reduce restrictive practices and increase the quality of life for adults and young people who have a learning disability and whose behaviour presents a challenge to services supporting them.
When we first met Simon, he was attending a college placement during the daytime and had recently moved into a well appointed residential property with 24-hour support, shared with 3 other people. The provider of the support asked us to help them understand Simon’s behaviour. They were concerned as staff were being injured by Simon almost every day and they were using restraints to manage some of Simon’s behaviour. The restraints were used as a last resort to protect themselves and members of the public when out; however, they were being used at least twice a month which gave both us and the support service cause for concern. There was therefore an urgent need to reduce restrictive practices.
As a result of the physical aggression to others Simon was spending long periods of time alone in a lounge (unlocked) engaging in self stimulatory repetitive behaviours. Simon appeared to be choosing to spend alone in the lounge and he appeared settled during these times. However, everyone was aware that in the long term this was not good for Simon as it was restrictive in terms of contact with others and activities. His quality of life was therefore quite poor. At college Simon was also spending long periods of time occupied in self stimulatory activity.
The Cycle of Issues We Identified
On completion of our functional behaviour assessment we identified that Simon’s behaviour resulted in him escaping contact with others. We also identified that Simon was only able to say one word/sound which, depending on pronunciation could mean ‘yes, I want that’ or ‘no, go away’ and this was also important in understanding him and his needs. Looking at Simons history and current setting it was clear that his behaviour functioned well to protect him from unwanted contact or difficult/confusing requests. However, the behaviour and the staff response were stuck in a cycle, sometimes with the behaviour ending in a restraint resulting in Simon continuing to be motivated to avoid staff contact by behaving in physically aggressive ways towards staff.
We discussed this cycle with staff alongside Simon’s history, so they could gain an understanding of what was happening and how their reaction was further compounding the problem by increasing Simon’s motivation to remove them from close proximity to him. Staff found this discussion helpful as we could then explain why Simon had kicked a member of staff as she offered him a cup of tea while placing it on the floor near him. Staff had been struggling to understand this event because it was not a request – they were not trying to get Simon to do anything – they were giving him something he liked and had agreed he wanted.
The Solution We Put in Place
We talked with staff about how they could build up ‘trust’ with Simon and agreed a behavioural plan which involved linking or ‘pairing’ staff with things that Simon liked, ensuring very short positive interactions. During the initial part of the intervention Simon stopped attending his college placement as it was agreed he was not accessing the education elements through his attendance.
Over the course of a number of weeks we gradually increased the time staff spent in proximity with Simon, items they provided him with during these sessions gradually decreased and the social contact became more important. At first the intervention was implemented by a core team of staff. We also did some trouble-shooting with the staff team around consistency and bringing in new team members. Staff recorded their actions on a simple recording sheet, so we could see how often they were following the plan and if any physical aggression occurred. Apart from a very few minor incidents the plan progressed well and staff didn’t get injured. This helped to build their confidence in supporting Simon.
Outside of the ‘PBS intervention points’, requests around personal care, meal times and drives were maintained, and all other non-essential requests were reduced. With a couple of weeks of the intervention being implemented the use of restraints had stopped completely. Within a few months staff were able to spend time in close proximity with Simon for over half an hour, with no physical aggression involved.
Why it Worked
The behavioural intervention worked because it helped Simon to trust those supporting him. We often find that once a person gains a level of trust with the people supporting them in an environment, the person then starts to trust new people in that same environment. This is because the environment shows them that ‘this is how people behave towards me here’. Along with this trust, the staff team’s confidence in supporting the person developed and together this turns the situation from a negative restrictive spiral to a positive one.
Our contact with Simon and the team continues, on a much less frequent basis. Simon no longer spends long periods of time alone engaging in self stimulatory behaviour and instead is very sociable, initiating social interactions with staff who are familiar but also with new staff. Through building up a trusting relationship with the staff team Simon has been able to develop many new independent skills and he now has a range of activities that he can enjoy both when he is at home and also when out in his local community. To achieve this part of the intervention we supported the staff team to use a structured skills assessment and skill teaching process; they are very enthusiastic about this and are always keen to look at new areas of skill development for Simon.
© Redstone PBS 2017
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Kate Strutt – Director of Redstone PBS and Clinical Psychologist. Kate has over 19 years’ experience of working in intellectual disability and autism services, both within statutory services and the independent sector. Kate is registered with the Health and Care Professions Council. Bsc Psychology, D.Clin Psyc, PG Certificate Applied Behaviour Analysis.
Natalie Savage – Board Certified Behaviour Analyst. Natalie has experience of working with children and adults in services and educational settings supporting people with intellectual disabilities, autism, social, emotional and behavioural difficulties (SEBD), dyslexia and behaviours that challenge. Natalie has an MSc in applied behaviour analysis (ABA) from Bangor University, Wales and an MA in Psychology with ABA from California State University Stanislaus, California.