Rules of engagement: toward an analysis of staff responses to challenging behavior

Challenging behaviour around challenging behaviour

INTRODUCTION

The United Kingdom's Department for Education's advice on behaviour focuses on the power of staff and the strength of the policy in challenging behaviour, via rules, sanctions and rewards. We designed a video-feedback intervention for staff teams in a special educational setting who were working with children with intellectual disability and challenging behaviour. The intervention aimed to raise reflective capacity on relational mechanisms that offer new response possibilities in everyday practices within trans-disciplinary teams.

METHOD

We conducted research with three teams (between five and seven participants in each). We report findings from two teams who were working with children (aged between 10 and 14) who staff identified as having behaviour that challenged. The intervention consisted of two video-feedback intervention sessions, using clips of good interactions between themselves and the child and a review. These sessions took place over three or four months. Qualitative analysis was conducted to analyse changes to the language and depictions of the children. Changes to the participants' goals during the intervention were also analysed.

RESULTS

The staff's focus on the child's challenging behaviour reduced. Children who were originally depicted as isolated became depicted in relationship with peers and staff. Participants became more curious about the child and his interactions in the school and home environment. The participant's personal goals emerged through their understandings of what it meant to be good.

CONCLUSIONS

Working with staff teams using video feedback can change the interactions around the child and the relational conceptualisation of the child and family. Further adaptations to the intervention are needed to raise critical reflection on the concepts that circulate around 'behaviour' that structure policy and shape everyday practices.

Support needs of parents with intellectual disabilities: Systematic review on the perceptions of parents and professionals

This review aimed to examine the perceptions of parents, professionals and informal network members regarding support needs of parents with intellectual disabilities (ID). In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, five databases were systematically searched and 19 qualitative studies were reviewed using thematic analyses. No data were available on the perceptions of the informal social network. Data on parents and professionals were categorized in four themes (type of support, sources of support, conditions of successful support and characteristics of support members). Data from professionals did not refer to emotional support needs or to the potential support of volunteers, friends and neighbours. Data from parents indicated a preference to be treated as 'full' parents, whereas professionals tended to focus on disabilities of parents. Results and implications contribute to insights into support needs of parents with ID from different perspectives and may help identify new entry points to improve future interventions and working alliances.

Survey of Japanese Welfare Facility Staff and Special School Teachers Facing Difficulties at Work with Persons with Challenging Behaviors

BACKGROUND

Effective training programs for managing people with challenging behaviors should be established in both welfare and education settings, as it is important that the support system for challenging behaviors covers the entire life span. For consistent support, it is necessary to understand the difficulties and needs of support staff in caring for people with challenging behaviors from infancy through adulthood. The purpose of this study was to gather data from welfare facility staff and special school teachers regarding their difficulties and needs for managing challenging behaviors, and to determine the differences between teachers and staff members.

METHODS

We investigated Japanese special school teachers (n = 317) and the staff of welfare facilities for intellectual disabilities (n = 202) regarding their difficulties and needs. The questionnaire comprised 23 items related to the needs and difficulties in responding to challenging behaviors.

RESULTS

Three factors were extracted from the analysis of the survey items: "Difficulty in coordination and information sharing with other organizations," "Difficulty in the workplace," and "Difficulty in support and response." The overall trend was that welfare staff have more difficulties and needs than special school teachers.

CONCLUSION

It is necessary to emphasize not only how to respond to challenging behavior but also the importance of establishing a collaborative system within the workplace and with other organizations for staff training in light of their perceptions of working conditions.

Health and Social Care Workers’ Understanding of the Meaning and Management of Challenging Behaviour in Learning Disability Services

The present study sought to investigate the relationship between professional background, length of experience, understanding of the term ‘challenging behaviour’ and opinions of factors important in managing challenging behaviour in people with learning disabilities. Health workers identified significantly more definition criteria than social care workers, yet no significant difference was found between their overall scores for management criteria. Rather, the emphasis of their knowledge of management principles appeared to be different. A significantly greater percentage of health workers identified management criteria relating to psychological principles, while a greater percentage of social care workers identified that of reactive responses. Health workers seemed more likely to identify challenging behaviour in terms of its impact on the service while social care workers appeared to concentrate on the type of behaviour evident. Finally, the longer the experience of the social care worker, the higher their overall scores for the definition and management criteria. However, no significant relationship was found between experience and overall scores amongst health workers. Implications of the findings are discussed.

Assessments and Interventions to Address Challenging Behavior in Individuals with Intellectual Disability and Autism Spectrum Disorder in Japan: A Consolidated Review

Intellectual disability and autism spectrum disorder are neurodevelopmental disorders that emerge during the developmental period. A significant barrier that impedes the social adaptation of individuals with these disorders is the exhibition of problem behaviors, such as self-injurious, stereotyped, and aggressive/destructive behaviors. In recent years, these problem behaviors have been collectively referred to as "challenging behavior," in accordance with the contention that they result from an interaction between the individual and his or her social environment. Evidence-based psychosocial interventions that adopt the functional approach to treating challenging behavior are increasing. However, in order to effectively implement such interventions in educational settings and welfare facilities, it is essential to develop staff training programs and usable psychometric assessments. Accordingly, a brief overview of research studies on challenging behavior that have been conducted in Japan, as well as the various support systems that are available to individuals who exhibit challenging behavior, are presented in this article. The discussion makes it apparent that, in order to improve treatment systems in Japan that are aimed at addressing challenging behavior, it is necessary to establish not only better staff training programs, but also reliable and valid assessments measuring challenging behavior that can be readily used by teachers and parents. On the basis of this discussion, it is proposed that technological advancements must be applied to psychosocial approaches in the study of problem behaviors, in order to develop assessment system using software applications and automatic measurement system of target behaviors using sensing technology.

Who's challenging who training for staff empathy towards adults with challenging behaviour: cluster randomised controlled trial

BACKGROUND

One in five adults with intellectual disabilities (ID) known to services display challenging behaviours (CBs), and these individuals are at risk for restrictive practices and poor care. Staff attitudes may contribute to the development and/or maintenance of CBs. We investigated the effectiveness of co-produced Who's Challenging Who? training delivered by people with ID to staff.

METHOD

This study involved a cluster randomised controlled trial (RCT) of Who's Challenging Who? training with follow-up at six and 20 weeks post-randomisation.

PARTICIPANTS

two staff from each of 118 residential care settings for adults with ID at least one of whom displayed aggressive CB.

PRIMARY OUTCOME

Self-reported Staff Empathy for people with Challenging Behaviour Questionnaire.

ANALYSIS

intention to treat of all randomised settings. ISCRTN registration: ISRCTN53763600.

RESULTS

118 residential settings (including 236 staff) were randomised to either receive training (59 settings) or to receive training after a delay (59 settings). The primary analysis included data from 121 staff in 76 settings (51% of staff, 64% of settings). The adjusted mean difference on the transformed (cubed) Staff Empathy for people with Challenging Behaviour Questionnaire score at the primary end point was 1073.2 (95% CI: -938.1 to 3084.5, P = 0.296) in favour of the intervention group (effect size Cohen's d = .19).

CONCLUSIONS

This is the first large-scale RCT of a co-produced training course delivered by people with ID. Findings indicated a small positive (but statistically non-significant) effect on increased staff empathy at 20 weeks, and small to moderate effects for staff reported secondary outcomes in favour of the intervention group.

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 synthesized narratively (RQ2; studies = 10).

RESULTS

By follow-up (6 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: 0.32-0.93) 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 organizational readiness appear crucial for maintaining implementation.

Effectiveness of the 'Who's Challenging Who' support staff training intervention to improve attitudes and empathy towards adults with intellectual disability and challenging behaviours: study protocol for a cluster randomised controlled trial

Background

Findings suggest approximately one in six people with intellectual disability engage in ‘challenging behaviours’, which include aggression towards others/property and self-injurious actions. In residential settings, actions of staff members can make challenging behaviours more likely to occur, or make these behaviours worse. In particular, negative attitudes from members of staff and lack of understanding about the reasons for challenging behaviour are contributory factors. ‘Who’s Challenging Who?’ (WCW) training is designed to emphasise the role of staff in residential settings as a challenge also to people with intellectual disability. The course is delivered jointly by a trainer with intellectual disability who has been labelled as having challenging behaviour, along with a trainer without intellectual disability.

Methods

This is a cluster randomised two-arm trial of WCW training versus a waiting list control. Overall, 118 residential settings will be recruited and randomised on a 1:1 ratio. Within each setting, two members of staff will be invited to take part in the trial. Participants will complete assessments at baseline and at 6 and 20 weeks. WCW is a half day initial training course with some follow-on coaching to ensure implementation. The primary outcome is changes in staff empathy towards people with challenging behaviour. Secondary outcomes at the staff level include confidence, attitudes and work-related well-being. Secondary outcomes at the residential setting level include recorded incidents of aggressive challenging behaviour, and use of any restrictive practices.

Discussion

If the results of the cluster randomised trial are positive, we will disseminate the findings widely and make all training manuals and materials freely available for anyone in intellectual disability services (and beyond) to use. Our training approach may have wider implications in other areas of social care. It may also provide a generally applicable model for how to train people with intellectual disability to act as co-trainers in intellectual disability social care settings. People with intellectual disability and challenging behaviour have already been involved centrally with the design, development and pilot evaluation of WCW and will also be fully involved throughout this trial.

Trial registration

Registered on the International Standard Randomised Controlled Trial Number registry on 8th December 2015: ISRCTN53763600.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2175-1) contains supplementary material, which is available to authorized users.

Functional Assessment and Challenging Behaviors: Some Future Directions

Behavior analysts have had a significant impact on the analysis and intervention of challenging behaviors in persons with developmental disabilities. These successes are celebrated in the first part of this article. In the remainder of the article, we present a selective discussion of three issues that we hope will help to further stimulate work with challenging behaviors: (a) the development of challenging behaviors, (b) the role of rule-governance in challenging behavior, and (c) the behavior of persons (mediators) who directly apply functional assessment and intervention technologies. Each of these issues is discussed and implications are drawn for future reseach and practice in the field. In drawing some conclusions, we focus on the internal and external validity of functional assessment and interventions.

Restraints in daily care for people with moderate intellectual disabilities

BACKGROUND

Self-determination is an important factor in improving the quality of life of people with moderate intellectual disabilities. A focus on self-determination implies that restraints on the freedom of people with intellectual disabilities should be decreased. In addition, according to the Dutch Care and Coercion bill, regular restraints of freedom, such as restrictions on choice of food or whom to visit, should be discouraged. Such restraints are only allowed if there is the threat of serious harm for the clients or their surroundings.

RESEARCH QUESTION

What do support staff consider as restraints on freedom and how do they justify these restraints?

RESEARCH DESIGN

In this study, data were collected by semi-structured interviews. Participants and research context: Fifteen support staff working with clients with moderate intellectual disabilities were interviewed. All participants work within the same organisation for people with intellectual disabilities in the Eastern part of the Netherlands. Ethical considerations: The study was conducted according to good scientific inquiry guidelines and ethical approval was obtained from a university ethics committee.

FINDINGS

Most restraints of freedom were found to be centred around the basic elements in the life of the client, such as eating, drinking and sleeping. In justifying these restraints, support staff said that it was necessary to give clarity in what clients are supposed to do, to structure their life and to keep them from danger.

DISCUSSION

In the justification of restraints of freedom two ethical viewpoints, a principle-guided approach and an ethics of care approach, are opposing one other. Here, the self-determination theory can be helpful, while it combines the autonomy of the client, relatedness to others and the client's competence.

CONCLUSION

Despite the reasonable grounds support staff gave for restraining, it raises the question whether restraints of freedom are always in the interest of the client.

Allied health professionals' perceptions of the role of sensory integration therapy in managing challenging behaviours

Aim:

This study investigated allied health professionals' awareness and knowledge of the role of sensory integration therapy in managing challenging behaviours in children with various disabilities.

Methods:

Thirty allied health professionals (physiotherapist=4; occupational therapist=4; speech pathologist=2; paediatrician=1; physical medicine and rehabilitation specialist=1; psychologist=3; special needs educator=11; social worker=3; vocational instructor=1) with a minimum of three years' experience working with children with developmental and behavioural disorders participated in this study. Participants were invited to attend a face-fo-face interview, which included eight questions on behaviours exhibited due to sensory processing issues and two questions related to non-sensory processing issues.

Results:

Although the majority (81%) of participants had come across most of the behaviours and considered most of the identified behaviours as challenging behaviours, less than a quarter (21%) of participants could identify the causative role of sensory processing disorders and hence, did not identify the use of sensory integration therapy in managing these behaviours. However, the majority (67%) of participants indicated feeling ‘very competent’ at handling challenging behaviours.

Conclusions:

There is a need to develop training programmes that focus on sensory integration and applied behavioural analysis to facilitate multidisciplinary working and improve professional understanding.

Acceptance and commitment therapy-based self-management versus psychoeducation training for staff caring for clients with a personality disorder: a randomized controlled trial

People diagnosed with a personality disorder (PD) are often a stigmatized patient group. This can affect the care they receive, their progression, and the well-being of staff caring for them. Interventions targeted at health care professionals that aim to improve attitudes toward these patients and improve staff well-being do exist; however, evidence for their effectiveness is limited. The present study compared a self-management, Acceptance and Commitment Therapy-based training intervention (ACTr) with a Psychoeducation Training (PETr) intervention in their effectiveness in improving attitudes toward PD patients, staff-patient relations, and staff well-being. Both interventions were successful at improving attitudes and measures of staff-patient relations up to 6 months after training; however, staff well-being did not change for either group. The implications for staff training and future research are discussed.

The role of physiological arousal in the management of challenging behaviours in individuals with autistic spectrum disorders

Challenging behaviours restrict opportunities and choices for people with autistic spectrum disorders (ASD) and frequently lead to inappropriate and costly service interventions. Managing challenging behaviours of people with autism is an important area of research. This paper examines some of the evidence for the role of physiological arousal influencing these behaviours. Evidence from the emerging literature about sensory differences is examined. It is proposed that sensory reactivity is associated with hyperarousal; catatonic type behaviours are associated with low levels of reactivity (hypoarousal). A low arousal approach is proposed as a generalised strategy to managing challenging behaviours with ASD. The use of non-contingent reinforcement and antecedent control strategies are recommended for use with challenging behaviours which have a sensory component. Examples are provided to illustrate the approach. The implications of arousal and the use of physical interventions are discussed. It is proposed that arousal is a construct which has significant heuristic value for researchers and practitioners.

Attributions, criticism and warmth in mothers of children with intellectual disability and challenging behaviour: a pilot study

BACKGROUND

Associations between parental expressed emotion (EE) or parental attributions and the problem behaviours of children with intellectual disability (ID) have been explored in ID research. However, a more detailed examination of the attributional model of EE has not been reported. In the present study, we partially replicated and extended research focused on mothers of typically developing children with behaviour problems.

METHODS

Twenty-seven mothers of children with ID and behaviour problems aged 4-9 years were interviewed about their most problematic behaviours exhibited by their child, and completed a Five Minute Speech Sample. Interview transcripts and speech samples were coded for maternal EE and spontaneous causal attributions regarding the child's behaviour problems. Data were also collected on maternal well-being, and the child's behaviour problems.

RESULTS

Mothers typically made attributions that were internal to the child, controllable by the child, personal to the child and stable for the child. Maternal attributions of being able to control the child's behaviour were associated with high maternal criticism and low warmth. Maternal depression was more strongly associated with the child's behaviour problems when mothers were coded as high in criticism or low in warmth.

CONCLUSIONS

Patterns of maternal attributions about their child's behaviour problems and their consequences for maternal well-being and maternal-child relationships require more research attention. Implications for practice are discussed, including the potential for maternal attributions to be incompatible with the focus of positive behaviour supports offered to families.

Who's challenging who? Changing attitudes towards those whose behaviour challenges

BACKGROUND

Although staff attitudes towards individuals with intellectual disability (ID) whose behaviour challenges may be an important part of a positive support culture, very little research has focused on the development of training specifically designed to change staff attitudes. Positive contact is hypothesised to be an effective way to change attitudes towards stigmatised groups.

METHODS

We designed and developed a half day training package about the experiences of individuals whose behaviour challenges - Who's Challenging Who (WCW). The WCW package was delivered according to a manual by a trainer with ID and a professional without disability. Seventy-six staff from a variety of organisations participated in one of 10 WCW training sessions and provided data on their attitudes and empathy towards individuals whose behaviour challenges prior to the WCW training and immediately at the end of training. Staff also completed a post-training evaluation questionnaire.

RESULTS

A training package was successfully developed collaboratively with individuals whose behaviour challenges, and received very positive evaluations from staff participants. Short-term positive change was shown for empowerment and similarity attitudes, and staff empathy and self-efficacy. These outcomes were associated with small to moderate effect sizes.

CONCLUSIONS

Meaningful short-term positive staff attitude changes were found and the WCW training model was shown to be feasible. More robust research designs are needed for future evaluation. In addition, the function of an attitude change intervention such as WCW within organisations' training strategies requires further development.

The impact of staff and service user gender on staff responses towards adults with intellectual disabilities who display aggressive behaviour

BACKGROUND

The impact of staff and service user gender on responses of staff in intellectual disability (ID) services is poorly understood. The present study set out to assess the role of gender in influencing staff emotions, attributions and behavioural intentions in response to aggression displayed by adults with ID.

METHOD

A new scale measuring staff behavioural intentions was developed. A two × two (staff gender × service user gender) between subjects design was used to compare the responses of day and residential support staff to physical aggression by a hypothetical service user. In response to a vignette depicting a service user with ID assaulting a member of staff, 160 respondents completed measures of affective responses, causal attributions and behavioural intentions while imagining themselves as the target of the service user's assault.

RESULTS

Female participants reported feeling more fear/anxiety, more depression/anger and less confident/relaxed than male participants. The longer staff had worked with people with ID, the more likely they were to favour safety-focused behaviours. More confident female participants were less likely to favour safety-focused behaviours, but confidence had no effect on male participants' endorsement of these behaviours. Increased confidence in both was associated with lower agreement of safety-focused behaviours in relation to the female vignette, regardless of participant gender. The more control women believed the service user had over their behaviour, the more likely they were to choose safety-focused behaviours. Punitive behaviours were favoured more in response to the male rather than the female service user. Punitive behaviours were also favoured more by more junior staff and by participants who expected feeling more depressed/angry in response to the vignettes.

CONCLUSIONS

Both staff and service user gender influenced staff responses to aggression, yet the latter played a smaller role than expected. The role of gender in staff-service user interactions should be the focus of further research and should be considered in service delivery.

Staff's attitudes and reactions towards aggressive behaviour of clients with intellectual disabilities: a multi-level study

Data were collected from 121 staff members (20 direct support staff teams) on background characteristics of the individual staff members and their teams (gender, age, years of work experience, position and education), the frequency and form of aggression of clients with an intellectual disability (verbal or physical), staff members' attitudes towards aggression, and the types of behavioural interventions they executed (providing personal space and behavioural boundary-setting, restricting freedom and the use of coercive measures). Additionally, client group characteristics (age of clients, type of care and client's level of intellectual disability) were assessed. Multilevel analyses (individual and contextual level) were performed to examine the relations between all studied variables and the behavioural interventions. The results showed that for providing personal space and behavioural boundary-setting as well as for restricting freedom, the proportion of variance explained by the context (staff team and client group characteristics) was three times larger than the proportion of variance explained by individual staff member characteristics. For using coercive measures, the context even accounted for 66% of the variance, whereas only 8% was explained by individual staff member characteristics. A negative attitude towards aggression of the direct support team as a whole proved to be an especially strong predictor of using coercive measures. To diminish the use of coercive measures, interventions should therefore be directed towards influencing the attitude of direct support teams instead of individual staff members.

Thinking about challenging behavior: a repertory grid study of inpatient staff beliefs

Studies examining staff attitudes toward people with intellectual disability have traditionally used pre-determined categories and models or been open to researcher bias. The use of methods derived from personal construct psychology permits an objective investigation of staff views and attitudes without such limitations. Fourteen staff from an inpatient intellectual disability service were interviewed about their perceptions of clients with challenging behavior primarily using the repertory grid technique as developed from personal construct theory. Staff was found to construe their clients and their behaviors in a heterogeneous manner that was not readily reducible to a group average, and they did not make or use attributions about them in a consistent manner. Future research should incorporate work culture and the staff-client relationship. The results have implications for clinical decision making, team working, and clinical supervision.

Evidence for reciprocal interaction effects among adults with self-injury and their caregivers

Patterns of caregiver responses to client adaptive behavior were compared between adults with intellectual disabilities with and without self-injurious behavior. Participants with moderate to profound intellectual disability and self-injury (n=89) and age/IQ matched control participants (n=20) were selected from a large sample of adults living in a regional residential center. Approximately 45 minutes of direct observation data were collected for each participant during unstructured leisure time. Data were sequentially analyzed and Yule's Q scores derived and compared among groups. Results indicated that caregivers were more responsive to prosocial initiations and adaptive engagement among individuals with severe self-injurious behavior than to those with mild or no self-injurious behavior and that these responses were more likely to be in the form of a demand.

Staff behavior toward children and adolescents in a residential facility: a self-report questionnaire

The purpose of the present study was to examine psychometric properties of the Staff Behavior toward Clients questionnaire (SBC), a self-report measure for care staff working with children and adolescents with mild to borderline intellectual disabilities in residential care. Ninetynine care staff completed the SBC and the Strengths and Difficulties Questionnaire (SDQ) for 99 of their clients. Factor analysis revealed four factors (i.e. behavior regulation, client-directed care, teaching and empowerment). Results indicated excellent internal consistency of all factors and ability of the SBC to detect differences in client populations with respect to behavior problems. These data suggest that the SBC could provide a reliable and valid measure of staff behavior toward clients in residential facilities.

Verbal and nonverbal emotional behaviour of staff: a first attempt in the development of an observation instrument

It is common to use questionnaires and interviews to assess the emotions of staff who serve clients with intellectual disabilities. Remarkably, observations of actual staff behaviour and assessments of nonverbal expressions are usually not involved. In the present study, we have made a first start in the development of an observation instrument that registers both verbal and nonverbal expressions of emotion. Following extensive literature reviews, interviews with clinical experts and pilot observations, we have created an observation system and observed a team of staff members during a period of three months. Results revealed sufficient to good interrater reliabilities regarding the observation of the three forms of emotional expression: body movement, facial expression, and verbal utterances. Low levels of explained variances between the different forms of expression showed that predictive values were weak. This means that there is a surplue value of the observation of nonverbal emotional expressions as compared to existing instruments that base their assessment on verbal and/or written responses only.

Training staff serving clients with intellectual disabilities: a meta-analysis of aspects determining effectiveness

The last decades have seen increased emphasis on the quality of training for direct-care staff serving people with intellectual disabilities. Nevertheless, it is unclear what the key aspects of effective training are. Therefore, the aim of the present meta-analysis was to establish the ingredients (i.e., goals, format, and techniques) for staff training that are related to improvements of staff behaviour. Our literature search concentrated on studies that were published in a period of 20 years. Fifty-five studies met the criteria, resulting in 502 single-subject designs and 13 n>1 designs. Results revealed important information relevant to further improvement of clinical practice: (a) the combination of in-service with coaching-on-the-job is the most powerful format, (b) in in-service formats, one should use multiple techniques, and verbal feedback is particularly recommended, and (c) in coaching-on-the-job formats, verbal feedback should be part of the program, as well as praise and correction. To maximize effectiveness, program developers should carefully prepare training goals, training format, and training techniques, which will yield a profit for clinical practice.

Children with learning disabilities

Children with learning disabilities can present numerous challenges in the acute hospital setting. This review article examines the causes and presentations of learning disability, and considers some of the management strategies employed when these children present for surgery.

Care staff attributions about challenging behaviors in adults with intellectual disabilities

A number of researchers have explored the attributions that care staff make about challenging behavior. The expectation, based on behavioral and cognitive models, is that these attributions may help predict why staff inadvertently reinforce challenging behavior. Two studies of staff attributions about challenging behavior are reported. In the first, a high level of consistency in attributions across staff was found. In a second quasi-experimental study, staff made attributions about two known clients' behavior. Analysis of these data showed that attributions varied in a manner broadly consistent with the hypothesized functions of the behaviors. The weight of the evidence suggests that staff may be sensitive to the causes of challenging behavior. The practical implications of these data are discussed.

Early intensive behavioral intervention for children with autism: therapists' perspectives on achieving procedural fidelity

The variability in outcomes observed in home-based early intensive behavioral intervention for children with autism is likely in part to be the result of the quality of therapist performance. Therapist behavior in this context, however, is poorly understood. To achieve such an understanding, it will be necessary to specify how factors such as therapist, child and intervention program characteristics, as well as supervision and training provision, influence therapists' interactions with children. This study identified facilitating factors and barriers that therapists considered to influence their capacity to deliver early intensive behavioral intervention to young children with autism. Nineteen therapists associated with various service providers in the South of England were interviewed. In general, responses represented opposite poles of the same construct. For example, child factors such as compliance and competence were considered to facilitate instruction, whereas challenging behavior and lack of progress were perceived to hinder it. These issues are considered in the light of previous research on staff behavior in related contexts. The factors identified suggest specific avenues for questionnaire and experimental research to validate these findings, have implications for routine service provision and may help improve the outcomes of children receiving early intensive behavioral intervention.

Staff in services for people with intellectual disabilities: the impact of stress on attributions of challenging behaviour

BACKGROUND

There is a lack of a conceptual framework as to how stress and attribution variables interact and influence staff behaviour in response to challenging behaviour. To address this, a model is tested examining the impact of stress on attributions of challenging behaviour within Weiner's model of helping.

METHOD

A total of 107 staff working in community homes for people with intellectual disabilities completed a self-report questionnaire that measured stress, burnout, attributions, emotions, optimism and helping behaviour in response to challenging behaviour.

RESULTS

Partial support was found for the role of attributions and emotions. However, although staff reported high stress levels and moderate burnout, this did not appear to relate to their reporting of thoughts and feelings regarding challenging behaviour predicted by Weiner's helping model. It was not possible to fully test the helping model, as the 'help' variable was not normally distributed.

CONCLUSIONS

There was little evidence to suggest that stress has a primary role in determining staff responses when examined within Weiner's model of helping. Limited support in general was offered for Weiner's helping model. Potential conceptual difficulties and clinical implications are explored and alternative models for future research are discussed.

Knowing you: the interpersonal perceptions of staff towards aggressive individuals with mild to moderate intellectual disabilities in situations of conflict

OBJECTIVES

Staff attributions concerning challenging behaviour have been found to play a role in determining their responses. The emphasis in the literature has been on staff beliefs about the challenging behaviour itself. However, staff are also likely to be responding to the person engaging in the behaviour. The aim of this study was to explore workers' perceptions of individuals who are frequently aggressive.

DESIGN AND METHODS

Thirty-six staff members working with individuals presenting problems of frequent aggression participated in this study. They were interviewed about an incident of aggression involving the person they worked with. The semi-structured interview, based on a Rational Emotive Therapy format, aimed to tap into the emotions aroused in the staff members and interpersonal appraisals that they made at the time of the incident. The responses were content analyzed.

RESULTS

The strength of the staff member's emotional reactions were noteworthy. Furthermore, approximately half of the staff members believed that the clients' aggression was directed at them personally. In turn, the majority of staff members described their clients in negative terms, and said that their first impulse had been to confront the clients.

CONCLUSIONS

The findings suggest that interpersonal perceptions may have a role in determining staff responses to individuals who behave aggressively. The clinical and theoretical implications of the findings were discussed, alongside directions for future research.

Staff responses to challenging behaviour shown by people with dementia: an application of an attributional-emotional model of helping behaviour

There is some evidence to suggest that staff beliefs and emotional responses to challenging behaviour shown by clients are critical factors in guiding their responses to such behaviour. The purpose of this paper was to apply Weiner's cognitive-emotional model of helping behaviour to staff working with people with dementia who exhibit challenging behaviour. The paper also aimed to explore the impact of staff burnout and professional group upon participants' responses to real-life experiences of challenging behaviour. The participants were 25 nurses and 26 psychologists. Methods included questionnaire measures and coding of spoken attributions using the Leeds Attributional Coding System. Non-parametric tests measured between-group differences and correlations between the key variables. There were few differences between the two professional groups for the key variables. Optimism and sympathy were generally associated with willingness to help, and burnout was associated with less willingness to help, low optimism and negative emotional responses to clients' behaviour. No consistent or robust role was found for attributions. The results are discussed in relation to alternative factors, which may promote or reduce staff helping behaviour in the context of services for people with dementia.

Behavioral function effects on intervention acceptability and effectiveness for self-injurious behavior

A variety of variables have been found to augment perceived social validity of behavioral interventions. In the present study, potential effects of behavioral function were evaluated. Sixty students inexperienced in work with people with mental retardation, and 60 experienced staff watched one of two carefully matched acted videos depicting self-injury maintained by attention or escape from task demands. Participants were also told whether the self-injury depicted typically led to mild or severe consequences for the person filmed. Participants rated six interventions in terms of their acceptability and effectiveness for the behavior depicted. A hierarchy of acceptability was replicated: reinforcement-based procedures were rated as more acceptable and effective. There were also effects of behavior severity and rater experience. However, few effects of behavioral function were found. Potential implications of staff undifferentiated attitudes towards functional treatments are discussed.

Formal versus informal interventions for challenging behaviour in persons with intellectual disabilities

BACKGROUND

Although effective, humane treatments exist for persons with intellectual disabilities (ID) who have challenging behaviour, little research has examined the extent to which clients receive formal, documented vs. undocumented interventions.

METHODS

Caregivers (of 625 persons with ID living in community and institutional residences in Ontario, Canada) were interviewed to examine the prevalence of different types of interventions.

RESULTS

Overall, 55% of the 2506 different interventions (for 1464 target behaviours) were informal (i.e. lacking documented input from a professional, written intervention plans, and systematic evaluation). No significant differences emerged on formality of intervention across participant gender, age, level of ID, and type of residence. There were significantly more informal than formal behavioural interventions and counselling/psychotherapy, and no significant difference in the overall prevalence of formal and informal intrusive procedures. Behaviour control medications were paired more often with formal (67%) than informal interventions for dangerous behaviours. Formal interventions were associated with higher caregiver-reported estimates of behavioural improvement, higher inter-rater agreement on the descriptions of an individual client's target behaviours and interventions, and more caregiver training and supervision.

CONCLUSIONS

The low levels of intervention accountability, training and supervision may place many clients with challenging behaviour at increased risk for ineffective and unnecessary restrictive interventions, and physical abuse. The results of this survey stimulated the government to write province-wide standards (that have yet to be implemented).

Determinants of negative emotional reactions and causal beliefs about self-injurious behaviour: an experimental study

BACKGROUND

Caregivers' emotional and cognitive reactions to challenging behaviours have been identified as potential determinants of their reinforcing responses towards such behaviours. However, few studies have explored factors affecting caregivers' emotional and cognitive responses to challenging behaviours.

METHODS

Sixty students inexperienced in work with people with challenging behaviours and 60 experienced staff watched one of two carefully matched, acted videotapes depicting self-injury maintained by attention or escape-from-task demands. The participants were also told whether the self-injury depicted typically led to mild or severe consequences for the person filmed. The subjects completed measures of their negative emotional reactions to the self-injury and their behavioural causal beliefs about the behaviour depicted.

RESULTS

Analyses of variance revealed that students reported more negative emotional reactions and were less likely to endorse behavioural causal hypotheses. Those who watched the severe self-injury videotape also reported more negative emotional reactions. Two effects of the behavioural function of the depicted self-injury were also found: (1) attention-maintained self-injury was associated with higher levels of endorsement of behavioural causal hypotheses; and (2) severe attention-maintained self-injury led to the strongest negative emotional reactions, but only from students.

CONCLUSIONS

The effects of experience and behavioural function on emotional reactions and behavioural causal beliefs need to be explored in more detail in future research. If replicated, the present results have significant implications for theory and practice in the remediation of challenging behaviours and the support of care staff.

Responses of staff towards people with mild to moderate intellectual disability who behave aggressively: a cognitive emotional analysis

BACKGROUND

Traditionally, research into interactions between staff and adults with an intellectual disability who engage in challenging behaviour has been carried out within a behavioural paradigm. Recent work has begun to examine cognitive factors. The majority of this research has drawn upon Weiner's attributional model of helping behaviour. Moreover, staff responses have usually been investigated in relation to client vignettes of challenging behaviour.

METHOD

The present study involved 38 staff who worked with frequently aggressive clients and its aims were twofold: (1) to compare different methods of examining the cognitive and emotional responses of staff to aggression; namely, descriptive vignettes and real incidents of aggression which staff could recall; and (2) to attempt to replicate previous findings supportive of Weiner's model with a new carer group (day centre staff).

RESULTS

When staff responses were compared across the hypothetical and real scenarios, using a series of one-way analyses of variance, it was revealed that staff experienced more negative emotions in response to the real incidents of aggression. The present study produced little evidence in support of Weiner's model. However, it was found that staff perceptions of the aggressive clients were linked to their cognitive and emotional responses to the aggression.

CONCLUSION

The theoretical and clinical implications of these findings are considered, and the possible role played by interpersonal attributions in mediating staff responses to aggression is discussed.

Behavioural knowledge, causal beliefs and self-efficacy as predictors of special educators' emotional reactions to challenging behaviours

Theoretical models and emerging empirical data suggest that the emotional reactions of staff to challenging behaviours may affect their responses to challenging behaviours and their psychological well-being. However, there have been few studies focusing on factors related to staff emotional reactions. Seventy staff working in educational environments with children with intellectual disability and/or autism completed a self-report questionnaire that measured demographic factors, behavioural causal beliefs, behavioural knowledge, perceived self-efficacy, and emotional reactions to challenging behaviours. Regression analyses revealed that behavioural causal beliefs were a positive predictor, and self-efficacy and behavioural knowledge were negative predictors of negative emotional reactions to challenging behaviours. Staff with formal qualifications also reported more negative emotional reactions. No other demographic factors emerged as significant predictors. The results suggest that behavioural causal beliefs, low self-efficacy and low behavioural knowledge may make staff vulnerable to experiencing negative emotional reactions to challenging behaviours. Researchers and clinicians need to address these issues in staff who work with people with challenging behaviours.