Influence of the organizational environment on challenging behaviour in people with intellectual disabilities: Professionals' views

Assessing the Adequacy of the Physical, Social, and Attitudinal Environment to the Specific Needs of Young Adults With Cerebral Palsy: The European Adult Environment Questionnaire

OBJECTIVES

To present the development of the European Adult Environment Questionnaire (EAEQ), to assess to what extent it covers the International Classification of Functioning, Disability and Health (ICF), and to describe the adequacy of the physical, social, and attitudinal environment to the specific needs of young adults with cerebral palsy (CP).

DESIGN

Cross-sectional.

SETTING

Administrative regions in France, Germany, Italy, Portugal, and Sweden.

PARTICIPANTS

Young adults with CP (N=357), with varying severity profiles, aged 19-28 years at time of interview (2018-20).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Physical, social, and attitudinal environment unmet needs.

RESULTS

Relevant environmental factors (EFs) for young adults with CP were identified during focus groups in England and Portugal. EFs were mapped to the ICF environmental classification and the EAEQ analytical structure resulted from this linking procedure. It comprised 61 items, linked to 31 ICF environmental classification categories, and covered 4 of its 5 chapters. Content validity assessed with the bandwidth index (percentage coverage of ICF Core Sets for adults with CP) was satisfactory (79.3%). A descriptive analysis was carried out. Participants had a mean age of 24 years, 56% were men, 38% had severely limited mobility. Less than 16% reported unmet needs for EFs relating to home, college/work/day placement, and communication in the Products and technology chapter. Unmet needs were higher (>20%) for the other items in the Public use and Land development categories. Social support, attitudes, and understanding of relatives were often adequate to the participants' needs. The proportion of unmet needs varied by sex (women were more often concerned) and raised with increasing gross motor impairment.

CONCLUSION

The EAEQ describes in detail the adequacy of the environment to the specific needs of young adults with CP. Its ICF-based structure opens up possibilities for use in a universal conceptual framework.

Challenging Behavior in Context: A Case Study on How People, Space, and Activities Interact

AIM

We aim to gain insight into the interaction between challenging behavior as shown by individuals with an intellectual impairment, and space, and to explore the possibilities of using routinely collected data to this end.

BACKGROUND

Research on challenging behavior shown by intellectually impaired individuals links their behavior to context, which includes space. Unfortunately, research about this link is hard to conduct, since these individuals may have difficulties expressing themselves verbally and react extremely to sensory stimuli.

METHOD

We conducted a single-case study, focusing on a Dutch very-intensive care facility. We analyzed data routinely collected by the healthcare organization in search of time-space configurations that provide insights into the resident-space interaction. As sensitizing concepts, we used three different contexts the residents interact with-space, people, and activities.

FINDINGS

The study exemplified reported interactions that were direct, for example, between the residents and the spatial context, and indirect, for example, through other contexts (people and activities). Space impacts on residents' senses intensely and acts as a lightning rod for their perceived stress. People also influence residents substantially. Caregivers may both have positive or adverse effects, for example, absenteeism or schedule change. Co-residents may trigger challenging behavior directly by a mere presence or transfer of their stress. Transitions between activities cause unpredictability and are triggers for residents, which interact with space.

CONCLUSIONS

Living environments providing choice in nearness to the caregiver and distance to co-residents "high in tension," lowering thresholds for transitions, and facilitating predictability would be beneficial for intellectually impaired individuals showing challenging behavior.

Transitions for older people with intellectual disabilities and behaviours that challenge others: A rapid scoping review

BACKGROUND

People with intellectual disabilities and behaviours that challenge others are living longer. This review aimed to explore what is known about the health and social care needs, experiences, service interventions and resources of and for this population as they transition to different care contexts in the UK.

METHOD

A rapid scoping review of published and unpublished literature was conducted based on collaborative working with key stakeholders and using systematic methods of data searching, extraction and analysis.

RESULTS

Consistent social work support, skilled staff, suitable accommodation, creative engagement with individuals and families to plan ahead, and timely access to quality healthcare are all required to promote successful transitions as people age, and to avoid unwanted/inappropriate transitions at points of crisis.

CONCLUSIONS

More research is needed to assess the types of services that this population can and do access as they age, the quality of those services, and the extent to which local commissioners are planning ahead for people with intellectual disabilities and behaviours that challenge others.

'Environments of concern': reframing challenging behaviour within a human rights approach

While disability is recognised by the United Nations Convention on the Rights of Persons with Disabilities (CRPD) as an evolving concept, the language of positive behaviour support has not kept pace with the current human rights-based approach. The widely-used terms 'challenging behaviour' and 'behaviours that challenge' imply that the behaviour is inherent in a person with disability. Words have power in shaping practice: when the behaviour of the person with disability is framed as the problem, this leads to a pathologisation or labelling that can provide a rationale to medicate and restrain as a way of 'managing the challenging behaviour'. Many behaviours seen as being challenging could be better understood as 'adaptive behaviours to maladaptive environments', or legitimate responses to difficult environments and situations. In this paper, we argue that the language and implementation of positive behaviour support should better take into account the CRPD and contemporary evidence on behaviour change interventions, which support a shift away from focusing on individuals' behaviours towards putting environments front and centre. We outline how the social-ecological model could be used as a framework to more explicitly address 'environments of concern' in developing tailored and system-wide responses to behaviour support needs. We argue there is an urgency for this paradigm shift to better reflect the views of people with disability and improve outcomes.

Consultations for refractory cases in mental health services: a descriptive study

BACKGROUND

Yearly, almost six percent, which is more than 1,000.000 people, in the Netherlands receive mental health treatment, which usually improves their quality of life. Concurrently, mental healthcare professionals recognize clinically refractory cases in which improvement fails to occur, with severe ongoing burdens for patients. The Dutch Centre for Consultation and Expertise (CCE) is available to support such refractory cases. The Dutch government's (financial) facilitation of consultation through the CCE is unique in the world. CCE consultations provide therefore unique insight into and an overview of refractory cases in mental health services. The objective of this study was to gain insight into the commonalities underlying the reasons for CCE consultations and the solutions proposed that play roles in (the reduction of) refractory cases for which consultation has been requested.

METHODS

This descriptive study was conducted with quantitative and qualitative data from 472 CCE consultations in the Netherlands. Using descriptive statistics and thematic content analysis, four exemplary situations were distilled from the qualitative data.

RESULTS

Most (83%) cases in the sample could be explained with four exemplary situations involving self-harm (24.2%), aggression (21.8%), self-neglect (24.4%), and socially unacceptable behavior (12.5%), respectively. Each situation could be characterized by a specific interaction pattern that unintentionally maintained or aggravated the situation. At the time of closure of the consultation applicants' questions had been answered and their situations had improved in 60.4% of cases.

CONCLUSIONS

This study offers an overview of approaches that provided new perspectives for patients and professionals in many refractory cases in the Dutch mental health services.

Setting up a new team of support staff for people with mild intellectual disability or borderline intellectual functioning and severe challenging behaviour: A concept mapping study

BACKGROUND

Studies about teams of staff supporting people with intellectual disability have focused on team performance of existing teams. This study aimed to examine important factors in the process of setting up a new team of support staff. Specifically, we considered the process for a team that supports service users with mild intellectual disability or borderline intellectual functioning who display severe challenging behaviour from the orthopedagogical perspective (i.e., with a focus on contextual factors).

METHOD

Three participant groups (service users, support staff, and professionals supporting a team) participated in a concept mapping procedure, including generating statements in interviews and focus groups, sorting, and rating. An expert group interpreted the results.

RESULTS

Important factors to one or more groups were: service users and support staff getting acquainted early, team safety, social support, a shared vision, and a positive reputation of the new home.

CONCLUSIONS

Four core outcomes were addressed that may help service organisations to provide an environment matching the needs of service users who show severe challenging behaviour from the start.

How does architecture contribute to reducing behaviours that challenge? A scoping review

BACKGROUND

Behaviours that challenge might prevent intellectually impaired individuals from experiencing a good quality of life (QoL). These behaviours arise in interaction with the environment and can be positively or negatively affected by architecture.

AIM

This scoping review explores how architecture contributes to the QoL of individuals engaging in such behaviours. It aims to identify possible gaps in the existing literature and map areas of future research.

METHOD

Four databases were searched using four concepts: architecture, intellectual impairment, challenging behaviour, and QoL. Since only one source covered all concepts, the search criteria were widened to include sources integrating only two or three concepts, nonpeer-reviewed sources, and autism. Eighteen papers, were analysed in terms of their contribution to relations between QoL, behaviours that challenge, and architecture.

RESULTS

This review shows that architecture, QoL, intellectual impairment, and behaviours that challenge have not yet been studied jointly.

CONCLUSIONS

The contribution of architecture to the QoL of these individuals should be subject of future research, together with the similarities and differences between their needs and those of individuals with autism.

A quantitative evaluation of a regional Positive Behavioural Support workforce development approach

BACKGROUND

Research suggests that providing staff with input in relation to Positive Behavioural Support (PBS) can have beneficial outcomes. Much of this research, however, fails to take account of systemic issues and does not include a control group.

METHOD

We used a non-randomised, controlled group design to evaluate accredited PBS programmes, delivered as part of a systemic, regional and workforce development approach. We compared outcomes of those attending the programmes (n = 240) with a control group (n = 54), pre- and post-intervention and at 3-months follow-up.

RESULTS

The programme and its wider impact were rated positively. Significant intervention effects were found for staff practice and retention, but not for staff knowledge and attributions, or behaviours that challenge and quality of life of those being supported.

CONCLUSIONS

The results are discussed in the context of the study limitations and restrictions resulting from the Covid-19 pandemic.

A multiple case study investigating changes in organizations serving residents with intellectual disabilities and challenging behaviours

BACKGROUND

the present authors examined changes made in disability service organizations supporting residents with intellectual disabilities and challenging behaviours, because these changes may influence residents' support and subsequently their challenging behaviours.

METHOD

In this multiple case study, the present authors collected and qualitatively analysed data (organizational documents, meetings records and focus group reports) on organizational changes made in two specialized Dutch disability service organizations, using ecological theory as a sensitizing framework and the constant comparative method.

RESULTS

Themes describing organizational changes in this context were as follows: a messy start to the transition; staff, professionals and managers remain at a distance; staff members' ability to change; clear boundaries between formal and informal caregivers; and staff's feelings of being unheard.

CONCLUSIONS

Organizational changes can enhance, but also limit, the quality of residential support services provided to people with intellectual disabilities and challenging behaviours. The change process and impact of organizational changes on residents must be examined closely.

Cross-sectional investigation of relationships between the organisational environment and challenging behaviours in support services for residents with intellectual disabilities

Background

This study was conducted to assess relationships between the organisational environment and three types of challenging behaviour (self-injurious, aggressive/destructive and stereotypical) in support services for residents with intellectual disabilities using ecological theory.

Method

A cross-sectional questionnaire-based design was used to identify relationships between ecological system aspects at multiple levels (micro-, meso-, exo-, macro- and chronosystems) and challenging behaviours of residents. A questionnaire was distributed to care professionals and managers working in specialised Dutch service organisations for residents with intellectual disabilities and challenging behaviour. The data were examined by Pearson correlation and multivariate regression analyses.

Results

The questionnaire was completed by 922 respondents from 21 organisations. Responses revealed that organisational aspects at the micro-, meso-, exo- and macrosystem levels play roles in residents' challenging behaviour. These aspects range from staff members' ability to sensitively interact with residents to grouping of residents with challenging behaviour, and staff turnover.

Conclusions

In the prevention and management of challenging behaviour of residents with intellectual disabilities, the consideration of ecological aspects at all system levels in the organisational environment is required.

Influence of the organizational environment on challenging behaviour in people with intellectual disabilities: Professionals' views

Background

We examined the influence of the organizational environment on challenging behaviour in people with intellectual disabilities to increase understanding of the quality of support services for people with intellectual disabilities.

Method

Twenty‐one professionals and managers from four specialized Dutch disability service organizations were interviewed. Data were analysed with a grounded theory approach, using Bronfenbrenner's ecological theory as a sensitizing frame.

Results

The organizational environment (i.e., vision, values, sufficient resources) is related via the support service (i.e., providing stability, constant awareness) to residents’ challenging behaviour and is also linked directly to challenging behaviour (e.g., living environment, values). Organizations are restricted by national regulations, negative media attention and changing societal values, which negatively influence quality of support.

Conclusions

The creation of a supportive organizational environment for staff, who in turn can provide quality support services to residents with demanding care needs, was found to prevent challenging behaviour in people with intellectual disabilities.