Systematic Review of Restraint Interventions for Challenging Behaviour Among Persons with Intellectual Disabilities: Focus on Effectiveness in Single-Case Experiments

A Pioneer Tool to Reduce Restrictive Practices toward People with Intellectual and Developmental Disabilities

Reducing restrictive practices toward individuals with intellectual and developmental disabilities is a globally recognized imperative and human rights priority. This paper presents a novel tool called LibRe for assessing and reducing restrictive practices. This tool involved an instrumental multistage design and collaboration between professionals, individuals with disabilities, family members, and experts from different fields. It addresses diverse restrictive practices in five key domains: physical or mechanical, chemical or pharmacological, structural, relational, and practices related to contexts and supports. It addresses practices that are pertinent to the Spanish context and that existing tools have not covered. Embedded as a step within an organizational approach, LibRe fosters organizational transformation and provides resources to achieve outcomes within reduction plans for restrictive practices. In total, 156 teams comprising 585 professionals, 64 people with disabilities, and 44 family members responded to the tool. In terms of evidence for internal structure validity, the oblique five-factor model exhibited an adequate fit through confirmatory factor analysis, along with satisfactory reliability indices, according to ordinal alpha and omega. Users positively appraised the tool's usefulness and identified its strengths and challenges. Although further research is needed, preliminary evidence frames LibRe as a useful resource for practice and research.

Using Non-Violent Discipline Tools: Evidence Suggesting the Importance of Attunement

Training in non-violent discipline is important to prevent violence against children and ensure that their caregivers remain a safe base for them. This paper aims to deepen understanding of non-violent discipline by exploring attunement as a mechanism in the effectiveness of non-violent discipline tools. Attunement describes the sensitive responsiveness of caregivers towards their children and has been found to be central to the formation of secure attachment bonds and development of self-regulation. It includes understanding or being "in tune with" the child's needs and signals, matching these with appropriate responses. The objective of this paper is to explore attunement in relation to non-violent discipline. Peer-reviewed systematic reviews previously included in a systematic overview of evidence on non-violent discipline options were screened for information relevant to attunement. All reviews were published in English between 1999 and 2018 and offered evidence on at least one non-violent discipline tool. Although no reviews explicitly addressed attunement, evidence was found suggesting its importance in the use and effectiveness of discipline methods. Research directly investigating attunement in discipline is needed.

Impact of the Care and Coercion Act on recorded involuntary care in intellectual disability care: a time-series analysis

BACKGROUND

On 1 January 2020, the Care and Coercion Act came into effect in the Netherlands, subjecting involuntary care to more strict regulations and monitoring. This study tested changes in recordings of involuntary care during the transitional year of 2020 and after full implementation in 2021, which coincided with the first severe test of the new regulations, when COVID-19 lockdown measures were taken on 16 March 2020.

METHODS

Data consisted of weekly counts of involuntary care from 1 January 2017 to 31 December 2021, taken from the care data of more than 3000 clients with intellectual disabilities and challenging behaviour of 's Heeren Loo, a large long-term care organisation in the Netherlands. An interrupted time series design was used to compare the period under the former law with the period under the new law and to the period during and after implementation, taking into account the impact of the COVID-19 lockdown measures on recordings of involuntary care.

RESULTS

Under the new act in Week 1 of 2020, a statistically significant drop occurred in involuntary care counts, after which these counts gradually decreased. The start of 2021, the year in which the act was fully implemented, showed an initial increase in counts of involuntary care, followed by a decrease (all Ps < .001). The introduction of the COVID-19 lockdown measures did not statistically affect the weekly counts of involuntary care.

CONCLUSIONS

The decrease in registered involuntary care after the Care and Coercion Act came into effect is a first indication of the efficacy of this new law that requires careful multidisciplinary consultations around the right of clients to respect their self-determination. Follow-up research should examine whether the impact of the new law aligns with clients' experiences of self-determination.

Characteristics of Moderators in Meta-Analyses of Single-Case Experimental Design Studies

Hierarchical linear modeling (HLM) has been recommended as a meta-analytic technique for the quantitative synthesis of single-case experimental design (SCED) studies. The HLM approach is flexible and can model a variety of different SCED data complexities, such as intervention heterogeneity. A major advantage of using HLM is that participant and-or study characteristics can be incorporated in the model in an attempt to explain intervention heterogeneity. The inclusion of moderators in the context of meta-analysis of SCED studies did not yet receive attention and is in need of methodological research. Prior to extending methodological work validating the hierarchical linear model including moderators at the different levels, an overview of characteristics of moderators typically encountered in the field is needed. This will inform design conditions to be embedded in future methodological studies and ensure that these conditions are realistic and representative for the field of SCED meta-analyses. This study presents the results of systematic review of SCED meta-analyses, with the particular focus on moderator characteristic. The initial search yielded a total of 910 articles and book chapters. After excluding duplicate studies and non peer-reviewed studies, 658 unique peer-reviewed studies were maintained and screened by two independent researchers. Sixty articles met the inclusion criteria and were eligible for data retrieval. The results of the analysis of moderator characteristics retrieved from these 60 meta-analyses are presented. The first part of the results section contains an overview of moderator characteristics per moderator level (within-participant level, participant level, and study level), including the types of moderators, the ratio of the number of moderators relative to the number of units at that level, the measurement scale, and the degree of missing data. The second part of the results section focuses on the metric used to quantify moderator effectiveness and the analysis approach. Based on the results of the systematic review, recommendations are given for conditions to be included in future methodological work.

The experiences of psychologists working with people with intellectual disabilities during the COVID-19 crisis

BACKGROUND

The aim of this study was to explore the experiences of psychologists working with people with intellectual disabilities during the initial stage of the COVID-19 lockdown in the Netherlands.

METHOD

Five psychologists, who were affiliated with three intellectual disability services, participated in this descriptive qualitative study. Overall, they recorded 22 audio messages during the period under examination, which were analysed using thematic analysis.

RESULTS

Three themes were identified: (a) Working from home; (b) Adapting to the new reality; and (c) Advising and coaching support staff.

CONCLUSIONS

This study provides critical insights into the experiences of psychologists working with people with intellectual disabilities during the initial stage of the COVID-19 lockdown. These insights can help policymakers and practitioners to prepare for either a potential second wave of COVID-19 or a future pandemic.

Bayesian Analysis for Multiple-baseline Studies Where the Variance Differs across Cases in OpenBUGS

Objective: There is a growing interest in the potential benefits of applying Bayesian estimation for multilevel models of SCED data. Methodological studies have shown that Bayesian estimation resolves convergence issues, can be adequate for the small sample, and can improve the accuracy of the variance components. Despite the potential benefits, the lack of accessibility to software codes makes it difficult for applied researchers to implement Bayesian estimation in their studies. The purpose of this article is to illustrate a feasible way to implement Bayesian estimation using OpenBUGS software to analyze a complex SCED model where within-participants variability and autocorrelation may differ across cases. Method: By using extracted data from a published study, step-by-step guidance in analyzing the data using OpenBUGS software is provided, including (1) model specification, (2) prior distributions, (3) data entering, (4) model estimation, (5) convergence criteria, and (6) posterior inferences and interpretations. Result: Full codes for the analysis are provided.

The Behavioral and Psychological Symptoms of Dementia in Down Syndrome Scale (BPSD-DS II): Optimization and Further Validation

BACKGROUND

People with Down syndrome (DS) are at high risk to develop Alzheimer's disease dementia (AD). Behavioral and psychological symptoms of dementia (BPSD) are common and may also serve as early signals for dementia. However, comprehensive evaluation scales for BPSD, adapted to DS, are lacking. Therefore, we previously developed the BPSD-DS scale to identify behavioral changes between the last six months and pre-existing life-long characteristic behavior.

OBJECTIVE

To optimize and further study the scale (discriminative ability and reliability) in a large representative DS study population.

METHODS

Optimization was based on item irrelevance and clinical experiences obtained in the initial study. Using the shortened and refined BPSD-DS II, informant interviews were conducted to evaluate 524 individuals with DS grouped according to dementia status: no dementia (DS, N = 292), questionable dementia (DS + Q, N = 119), and clinically diagnosed dementia (DS + AD, N = 113).

RESULTS

Comparing item change scores between groups revealed prominent changes in frequency and severity for anxious, sleep-related, irritable, restless/stereotypic, apathetic, depressive, and eating/drinking behavior. For most items, the proportion of individuals displaying an increased frequency was highest in DS + AD, intermediate in DS + Q, and lowest in DS. For various items within sections about anxious, sleep-related, irritable, apathetic, and depressive behaviors, the proportion of individuals showing an increased frequency was already substantial in DS + Q, suggesting that these changes may serve as early signals of AD in DS. Reliability data were promising.

CONCLUSION

The optimized scale yields largely similar results as obtained with the initial version. Systematically evaluating BPSD in DS may increase understanding of changes among caregivers and (timely) adaptation of care/treatment.

Residents' and resident representatives' perspectives on the influence of the organisational environment on challenging behaviour

BACKGROUND

This study explored the perspectives of residents of residential disability service organisations and resident representatives on the influence of the organisational environment on challenging behaviour in people with intellectual disabilities (ID).

METHOD

Sixteen residents and representatives from four specialised Dutch disability service organisations were interviewed. Data were analysed using a grounded theory approach, with a sensitising frame based on Bronfenbrenner's ecological theory.

RESULTS

Some organisational factors (e.g. staff turnover, insufficient finances) can have negative effects on interactions among residents and staff and family members, resulting in more challenging behaviour, but other organisational factors (e.g. shared vision, values and expectations, competent staff) can positively influence staffs' attitudes and actions, which in turn helps to manage challenging behaviour in people with ID.

CONCLUSIONS

Residents' and representatives' perspectives provide a better understanding of the positive and negative influences of the organisational environment on challenging behaviour in people with ID.

Stakeholders' perspectives on how to improve the support for persons with an intellectual disability and challenging behaviors: a concept mapping study

INTRODUCTION

People with an intellectual disability (ID) are at risk of developing challenging behavior. Although previous research provided important insights into how to support people with an ID and challenging behavior, it remains unclear what various stakeholders consider to be the most essential aspects to further improve their support.

METHOD

Statements regarding aspects perceived necessary to improve the support to people with an ID and challenging behavior were collected in focus groups. Afterwards participants individually prioritized and clustered these statements, resulting in concept maps for people with an ID, direct support workers, and psychologists. Since only three relatives participated in the entire concept mapping procedure, no concept map could be composed based on their input.

RESULTS

Participants generated 200 statements. In the concept map of clients, statements were mentioned regarding relational aspects, providing clarity and structure, characteristics of support staff, and professional attitude of direct support workers. Direct support workers provided statements related to their own personal competencies, the necessity of feeling supported and appreciated, and a physical safe environment. Psychologists provided statements regarding their support for direct support workers, the support for the clients, the perspective on the client, and their role as psychologists.

CONCLUSION

The results of this study may be a starting point to foster increased evidence based practice for the support for persons with an ID and challenging behavior. Moreover, it provides opportunities to create care founded on mutual attunement, based on listening to each other's ideas and insight into perspectives and needs of various stakeholders.

Restraint interventions in people with moderate to profound intellectual disabilities: Perspectives of support staff and family members

BACKGROUND

Due to incompatibilities in communication, it is key that family members and support staff can take the perspective of people with moderate to profound intellectual disabilities (ID) whilst putting aside their own perspectives.

METHOD

Ten vignettes describing types of restraint interventions (RIs) were presented to 20 unique pairs of support staff and family members related to individuals with moderate to profound ID.

RESULTS

In taking their own perspective, more than half of the support staff and family members perceived all RIs as involuntary and severe. In contrast, when asked to put themselves in the position of the client/family member, only three RIs were considered involuntary by a majority of support staff and family members.

CONCLUSIONS

These results indicate that support staff and family members can take into account the perspective of people with moderate to profound ID in the evaluation and consideration of involuntary care.

Meta-Analysis of Single-Case Research via Multilevel Models: Fundamental Concepts and Methodological Considerations

Multilevel modeling is an approach that can be used to summarize single-case experimental design (SCED) data. Multilevel models were developed to analyze hierarchical structured data with units at a lower level nested within higher level units. SCEDs use time series data collected from multiple cases (or subjects) within a study that allow researchers to investigate intervention effectiveness at the individual level and also to investigate how these individual intervention effects change over time. There is an increased interest in the field regarding how SCEDs can be used to establish an evidence base for interventions by synthesizing data from a series of intervention studies. Although using multilevel models to meta-analyze SCED studies is promising, application is often hampered by being potentially excessively technical. First, this article provides an accessible description and overview of the potential of multilevel meta-analysis to combine SCED data. Second, a summary of the methodological evidence on the performance of multilevel models for meta-analysis is provided, which is useful given that such evidence is currently scattered over multiple technical articles in the literature. Third, the actual steps to perform a multilevel meta-analysis are outlined in a brief practical guide. Fourth, a suggestion for integrating the quantitative results with a visual representation is provided.

The patient/significant other experience of physical restraint in acute care settings: a qualitative systematic review protocol

REVIEW QUESTION

The overarching question for this qualitative systematic review is: What meanings are attributed to the experience of physical restraint among adult patients or their significant others in acute care hospitals? Specifically the review will seek to answer two questions.

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.

Functional analysis and treatment of problem behavior exhibited by children with fragile X syndrome

The efficacy of function-based interventions for the treatment of severe problem behavior exhibited by individuals with intellectual and developmental disabilities (IDD) is well established. However, few studies have reported on behavioral interventions in fragile X syndrome (FXS) specifically. The present study is a consecutive case-series analysis that reports on functional analysis and treatment of problem behavior of nine children with FXS. Assessment findings were consistent with previous research indicating that among individuals with FXS, problem behavior is more commonly maintained by escape from demands and access to tangible items, relative to the broader population of individuals with IDD. Functional analysis-based behavioral interventions resulted in a mean reduction in problem behavior of 95.2% across the nine participants. Additionally, generalization of treatment effects from controlled clinical settings to home, school, and community was demonstrated. The current findings suggest that function-based behavioral interventions shown to be effective with the broader population of individuals with IDD are also effective for individuals with FXS. Our results in combination with those of previous studies describing functional analysis outcomes provide additional evidence for a unique functional behavioral phenotype for severe problem behavior in individuals with FXS. Implications of study findings for early intervention and prevention of problem behavior in children with FXS are discussed.

Parental Perceptions of the Use of Coercive Measures on Children with Developmental Disabilities

BACKGROUND

Children with developmental disabilities who exhibit challenging behaviour are potentially subject to the use of coercive interventions. The aim of the study was to investigate the prevalence of the use of coercive measures by authorities, according to parents' reports.

MATERIALS AND METHODS

A postal survey was distributed, as a total population study, to 946 Finnish parents of children with developmental disabilities, between the ages of 5 and 15, and who were entitled to the highest disability allowance.

RESULTS

Of the respondents, 54 (22%) answered 'yes' when asked whether their child had been subjected to coercive procedures by authorities. The parents had seldom approved the use of coercive means and often believed that such means had negative effects on their child.

CONCLUSIONS

To protect the children's rights, the use of coercive measures should be regulated more strictly, and positive intervention strategies should be taught to teachers and nurses.

Efficacy of behavioral interventions for reducing problem behavior in persons with autism: an updated quantitative synthesis of single-subject research

Problem or challenging behaviors are highly prevalent among persons with autism and bring along major risks for the individual with autism and his/her family. In order to reduce the problem behavior, several behavioral interventions are used. We conducted a quantitative synthesis of single-subject studies to examine the efficacy of behavioral interventions for reducing problem behavior in persons with autism. Two hundred and thirteen studies representing 358 persons with autism met the inclusion criteria and were included in the statistical analyses. Overall, we found that behavioral interventions were on average effective in reducing problem behavior in individuals with autism, but some interventions were significantly more effective than others. The results further showed that the use of positive (nonaversive) behavioral interventions was increasing over time. The behavioral interventions were on average equally effective regardless of the type of problem behavior that was targeted. Interventions preceded by a functional analysis reduced problem behavior significantly more than interventions not preceded by a functional analysis. Finally, treatment and experimental characteristics, but not participant characteristics, were statistically significant moderators of the behavioral treatment effectiveness.