ArticlePDF Available

The effects of staff training on staff confidence and challenging behavior in services for people with autism spectrum disorders



The effects of a 3-day training course in the management of aggressive behavior in services for people with autism spectrum disorders were investigated using a quasi-experimental design. An experimental group received training over a 10-month period and a contrast group, which had received training before this study, did not. Staff training increased carer confidence, but there were no training effects of measures of staff coping, support or perceived control of challenging behaviors. Staff reports of service user challenging behavior management difficulties decreased in both the experimental and contrast groups. This study showed that staff training can increase staff confidence in managing aggression in people with autism spectrum disorders.
Staff training and aggression
The effects of staff training on staff confidence and
challenging behavior in services for people with autism
spectrum disorders.
McDonnell, A., Sturmey, P., Oliver, C., Cunningham, S,
Hayes, S., Galvin, M., Walshe, C. and Cunningham, C.
Cerebra Centre for Neurodevelopmental Disorders,
School of Psychology,
University of Birmingham
Please use this reference when citing this work:
McDonnell, A., Sturmey, P., Oliver, C., Cunningham, S, Hayes, S., Galvin, M., Walshe, C.
and Cunningham, C. (2008). The effects of staff training on staff confidence and
challenging behavior in services for people with autism spectrum disorders. Research in
Autism Spectrum Disorders, 2, 311-319. (DOI:10.1016/j.rasd.2007.08.001).
The Cerebra Centre for Neurodevelopmental Disorders,
School of Psychology, University of Birmingham, Edgbaston, Birmingham, B15 2TT
Website: E-mail:
Staff training and aggression
The effects of a 3 day training course in the management of aggressive behaviour in
services for people with autism spectrum disorders were investigated using a quasi-
experimental design. An experimental group received training over a 10-month period and
a contrast group, which had received training before this study, did not. Staff training
increased carer confidence, but there were no training effects of measures of staff coping,
support or perceived control of challenging behaviours. Staff reports of service user
challenging behaviour management difficulties decreased in both the experimental and
contrast groups. This study showed that staff training can increase staff confidence in
managing aggression in people with autism spectrum disorders.
Staff training and aggression
The effects of staff training on staff confidence and challenging behavior in services for
people with autism spectrum disorders.
Aggressive behavior in people with mental retardation in community settings is
shown by approximately 2-15% of children and adolescents and approximately 10-15% of
adults (Rojahn & Tasse, 1996.) Aggression has many negative consequences, including
rejection by peers, staff and family members, exclusion from integrated settings, use of
restrictive behavioral practices, increased use of psychotropic medications, injuries to self,
peers and staff, and increased costs (McDonell & Sturmey, 1993.) In response to this
problem a range of community-based services for aggressive and other challenging
behaviors have been developed (Allen, 2001, 2002; Hanson, Weisler, & Lakin, 2002)
A wide range of interventions have been developed for aggression in people with
mental retardation including those based on applied behavior analysis, psychotropic
medication and other methods of intervention. A distinction has been made between
planned behavioral interventions, such as environmental modifications and skills teaching,
and reactive strategies, such as unplanned restraint (Allen, 2001.) There is an extensive
literature on planned behavioral intervention (Carr et al.,1999; Didden, Duker & Cornelius,
1997; Scotti , Ujcich, Weigle, Holland & Kirk, 1996), but less attention has been paid to
evaluation of reactive strategies (Allen, 2001.)
There is some evidence that reactive strategies are widely used in community
settings. Emerson (2002) conducted several surveys of children and adults with mental
retardation in community services. He surveyed 107 children and adolescents with
challenging behaviour who lived in community settings and found that 67% of them had
their challenging behaviour managed ‘sometimes’ or usually’ managed by restraint. 68% by
Staff training and aggression
seclusion, and 6% by sedation. In a second survey of 68 children and adolescents with
intellectual disabilities 46% had experienced restraint, 67% seclusion, 2% sedation and 4%
medication over the preceding 6 months. In a third survey of 656 of children with
intellectual disabilities, 42% displayed challenging behavior. Of those who displayed
challenging behavior 28% had experienced physical restraint, 32% seclusion, 1% sedation
and 3% mechanical restraint over the preceding six months. Feldman, Atkinson, Foti-
Gervail and Condillac (2004) conducted a similar survey of formal and informal
interventions strategies in 625 clients with behavior problems in Ontario from 96 agencies.
Ninety-two per cent of the sample lived in community settings and 8% lived in institutions.
They found that 56% had experienced medication for behavior control, 12.3% had
experienced physical restraint, 11.4% had experienced confinement time-out, 5.9% had
experienced mechanical restraints and 4.5% had experienced seclusion. These restrictive
procedures were used both in formal programs and informally. Thus, data from both the
United Kingdom and Canada indicate that reactive and restrictive strategies are commonly
used in community settings.
In response to the need to implement reactive strategies more effectively a staff
training courses (Allen, 2001), social policy (Harris, 2002; Harris, Allen, Cornick,
Jefferson, & Mills, 1996)) and regional and state challenging behavioral services (Hanson,
et al., 2002) have been developed. Most staff training interventions have been evaluated
primarily through non-experimental pre- post-designs (Allen, 2001) although a number of
quasi-experimental and experimental studies have been conducted. Allen and Tynan (2000)
conducted a quasi-experimental study to evaluate the effects of a staff training course to
increase staff members’ knowledge of effective management of aggressive behavior and to
Staff training and aggression
increase their confidence in managing challenging behavior. Their design compared the
scores of one group of staff, who had already been trained, with the scores of an untrained
group of staff and then also compared the scores of the group of untrained staff prior to
training with their scores after training. They found that trained staff knew more and were
more confident that untrained staff. After training the scores on knowledge and confidence
for the experimental group increased significantly. Other quasi-experimental and
experimental studies have found similar benefits of staff training for psychiatric hospital
staff (Phillips & Rudenstam, 1995; Rice, Helzel, Varney & Quinsey, 1985) and nursing
students, although one study found staff training to be ineffective in changing staff
(Needham et al., 2004a, 2004b, 2004c.) Finally, Van den Pol, Reid and Fuqua (1983) used
a single subject experimental design demonstrated that supervisors could be trained to teach
their staff to correctly implement reactive strategies using behavioral skills training. Thus,
although there are a number of quasi–experimental and experimental studies demonstrating
benefits of staff training, there number is limited and positive outcomes are not always
reported. Further, although studies have evaluated staff training procedures to better
manage challenging behaviors in adults and children with mental retardation, no studies
were identified that worked with services for people with autism spectrum disorders.
McDonell, (1997; McDonnell, Dearden, & Richens, 1991a, b, c) developed a course
to promote the use of simple preventative strategies, a low arousal approach to reducing
aggressive behaviours (McDonnell, Johnson, Reeves & Lane, 1998) and physical
interventions, which are designed to avoid pain and which are socially validated
(McDonnell, & Sturmey, 1993, 2000; McDonnell, Sturmey, & Dearden, 1993). Previous
non-experimental studies have demonstrated that it can reduce challenging behaviours and
Staff training and aggression
the use of restraint for individual clients (McDonell et al., 1998) as well as for entire units
(McDonnell & Reeves, 1996; McDonnell, Walters, Jones, 2002.) Evaluation of 15 courses
using a non-experimental pre-post design indicated that staff often gain confidence and
knowledge following the course (McDonell & Sturmey, in press.) Thus, there was a need
for a more rigorous evaluation of this staff training course in services for people with
autism spectrum disorders. Therefore, we conducted a quasi-experimental evaluation of this
three day course for 43 staff who received training and a contrast group of 47 community
staff who had previously received training.
Participants and settings
There were 90 participants in two service groups. There were 43 participants in the
training group. Twenty-eight (65%) were women and 15 (35%) were men. Ten (23%)
worked part-time, and 33 (77%) worked full time. Seven (16%) had worked for less than
one year, 9 (21%) for one to two years, 10 (23%) for 3 to 5 years and 17 (40%) for over
five years. There were 47 participants in the comparison group. Twenty-seven (57%) were
women and 20 (43%) were men. Sixteen (34%) worked part-time, and 31 (66%) worked
full time. Eight (17%) had worked for less than one year, 9 (19%) for one to two years, 12
(26%) for 3 to 5 years and 18 (38%) for over five years.
Both services provided care for adults diagnosed with autistic spectrum disorders.
The staff in the training group provided residential social care and day services to 30
service users in four group homes and a day service. The group homes ranged from a
dwelling with four individuals to one house with nine people. This service employed 50
staff. Staff in the comparison group provided residential social care and day services to 48
Staff training and aggression
service users in six group homes and two-day services. Between six and eight people lived
in the group homes.
Staff Training
All staff in the experimental group participated in the three-day training course
(McDonnell, 1997.) Half of this training course involved theoretical components, such as
legal issues, causes of aggressive behavior, staff support and low arousal approaches (The
remainder of the training course examined high frequency aggressive behaviors, such as
hair pulling, biting, grabbing, airway protection, and one form of two person service user
chair restraint in an upright posture. Teaching methods for the physical strategies involved
modeling methods with rehearsal using role play. Further details of the course content and
format can be found in previous publications (McDonnell et al., 1998; McDonnell, et al,
1991a, b, c; McDonnell et al, 1993.)
The three training courses took place over a period of ten months and were
conducted by the same trainers. The trainers completed a checklist of course content after
each course in order to ensure that the same material was covered on all courses. There was
100% agreement between the three training course that these items had been delivered.
The Staff Support and Satisfaction Questionnaire (3SQ) was a 21-item measure of
staff support (Harris & Rose, 2002). The 3SQ had good test retest reliability (r = 0.82) and
high levels of internal reliability (Cronbach's alpha = 0.92, (David, 1997). There were five
subscales: role clarity, coping resources, risk factors, supportive people and job satisfaction.
Each of the subscales contained items such as ' How clear are you about the main objectives
Staff training and aggression
you should be working towards in your job?' that were rated on a five-point Likert scale
from very clear/very satisfied/always to very unclear/very dissatisfied/never.
The Shortened Ways of Coping Scale (Hatton & Emerson, 1995) was a 14-item
measure with good reliability and internal consistency (average Cronbach's alpha = 0.76). It
had 2 subscales: Wishful Thinking (alpha =0.63) and Practical Coping (alpha = 0.76). The
Wishful Thinking subscale included items such as 'I daydream or imagine a better time or
place than the one I am in'. The Practical Coping subscale included items such as 'I think
up a couple of different solutions to problems'. Items on both of the scales were rated on a
four-point Likert scale from 'not used' to 'used a great deal'.
The Thoughts about Challenging Behavior Questionnaire was a 15-item measure,
which examined perceived controllability of staff behavior (Dagnan, 2002). Thoughts that
people may have when dealing with a person with a learning disability and challenging
behavior (e.g. 'they are trying to wind me up') were rated on a five-point Likert scale from
'agree strongly' to 'disagree strongly'. The internal consistency of the pre-training scores (N
= 43) was very high (alpha = 0.85).
The Challenging Behavior Confidence Scale (McDonnell, 1997) was a 15-item
measure of self-confidence. Statements about violent people, such as 'I would be able to
talk to a potentially violent person,' were rated on an eleven-point Likert scale reflecting
how confident participants would be to carry out any of the statements right at this moment.
Previous research has produced good internal consistency ratings (Cronbach's Alpha =
0.95; McDonnell, 1997).
The Checklist of Challenging Behavior (Harris, Humphreys & Thompson, 1994)
was a 34-item checklist of various extra-personal challenging behaviors for use with
Staff training and aggression
individuals with intellectual disabilities. The original checklist contained items, which
were collapsed categories "Punching, slapping, pushing or pulling". These items were
separated and the new items "Hitting Out (with open hand)", "Punching (clenched fist)”
and “Grabbing” were added. Items were rated on the frequency, severity of the injury
caused, and the management difficulty that the behavior posed to carers. Ratings were
based on behavior over the last three months and ranged from (1) “has not occurred to” (5)
“occur very often (daily)”. Severity ratings referred to the most serious injury caused by
the behavior and ranged from (1) “no injury” to (5) “very serious injury (caused very
serious tissue damage such as broken bones, deep lacerations/ wounds requiring
hospitalization and/or certified absences from work).” Management difficulty ratings were
related to how difficult the carers found the behavior to manage and was scored on a scale
of (1) “no problem (I can usually manage this situation with no difficulty at all”) to (5)
“extreme problem (I simply cannot manage this situation without help.”')
A quasi-experimental design was used (Campbell & Stanley, 1963). An
experimental group received training over a ten-month period. This training was compared
with a contrast group which had already received the same training system. There were
two-time periods for administration of the main measures. The time periods were
approximately ten months apart. Thus, if there had been an effect of training the scores on
the experimental group, but no the contrast group, should change (Campbell & Stanley,
1963.). Data were analyzed using two-way ANOVA’s and post hoc, Bonferroni corrected t-
Staff training and aggression
The measures were completed by a staff who had a good working knowledge of the
service users during part of structured interview. The interviewer said 'I am going to read
out a list of behaviors and I would like you to respond using the scales provided'. The
interviewer read the items out aloud. Staff then rated the items verbally. Wherever possible
the same staff completed the measures at time two. The staff measures were administered at
both time periods with the following instructions “Please answer the following questions on
your own before you talk to other staff about it. Do not put your name on the questionnaire,
as the results will be compiled to give group scores. The answers you give will be treated as
strictly confidential and only the group scores will be shown to others.”
Staff measures
The relationship between the four staff based measures was investigated using
Pearson's product moment correlations. Only one relationship approached significance
(3SQ vs. Thoughts about challenging behavior, r = 0.2, p <.06). The other correlations were
all non-significant. Hence, the measures were not inter-correlated.
The mean (and SD) pre- and post-training confidence scores were: Experimental
group / pre 92.1 (34.5), Experimental group / post 111.2 (30.5); Contrast group / pre 87.9
(28.1); and, Contrast group / post 88.0 (27.9). There were significant interaction (F [1, 171]
= 4.1, p < .05) and a main effect of service (F[1,171] = 9.23, p < .01). Post hoc Bonferroni
tests revealed that the contrast group scored significantly lower than the experimental
groups at both time 1 and time 2 (p<.05). Post hoc Bonferroni corrected t - tests revealed
that the only statistically significant differences were between the pre- and post-scores in
Staff training and aggression
the experimental group (p's < .01). Thus, staff training had an effect on staff confidence
There were no significant effects of time for the Thoughts about Challenging
Behavior Scale (F[1,171] = 1.37, p>.05) but there was significant main effects of group (F
[1, 171] = 23.9, p < .001). The ways of coping scale divides into two sub-scales ‘practical
coping’ and ‘wishful thinking’. The practical coping scale produced no main effect of time
(F[1,171] = 1.07, p>.05). There was an effect of group (F{1,171] = 7.90, p <.01). An
analysis of mean scores showed that the comparison group scored lower on this scale at
both time 1 and time 2. The wishful thinking sub-scale produced no significant main effects
of group (F[1,171] = .571, p>.05), or time (F[1,171] = .140, p>.05).
Staff Support Satisfaction measure produced no main effects of time (F[1, 171] =
2.62, p>.05) but there was a significant main effect of group (F 1, 171] = 85.7, p < .001)
which was also found on five subscales [ Role Clarity (F [1, 171] = 30.3, p < .001); Coping
Resources (F [1, 171] = 68.4, p < .001); Risk Factors (F [1, 171] = 81.9, p < .001);
Supportive People (F [1, 171] = 42.5, p < .001); and, Job Satisfaction (F [1, 171] = 42.7, p
< .001). These differences between the mean scores of the experimental and the
comparison group merely reflect the naturally occurring differences that existed between
the two, groups. There were no other significant effects.
Challenging Behavior Checklist
There was a main effect of time for management difficulty (F [1, 13] = 7.4, p <.02),
frequency (F [1, 13] = 5.6, p < .04) and severity (F [1,13] = 13.1, p <.005). There were no
other significant effects. Both groups reported lower ratings at time 2.
Staff training and aggression
This study found that staff training to better manage aggressive behaviors in people
with autism spectrum disorders increased staff confidence, but not other measures of staff
belief, support or coping. There was no evidence of a reduction in client challenging
behaviors as staff in both the treatment and contract group reported significant reductions in
challenging behaviors. There was no evidence that training effected staff support (Harris &
Rose, 2002), coping (Hatton & Emerson, 1995) or perceived control (Dagnan, 2002.) Thus,
there was only evidence that training impacted staff confidence.
We observed an effect on staff reports of service user challenging behaviors for
both groups. This may be because there truly were no effect of staff training on subjective
measures of aggressive behaviors or because the comparison group was an active rather
than passive comparison group. In such a situation one might expect the behavior
management ratings to decline in both groups. Another possibility is that this measure of
behavior may be insensitive or inaccurate. Thus, there may have been effects on client
challenging behaviors that would have been detectable through direct observation.
Alternatively, it may that in some circumstances that staff training using generic lectures,
modeling and role play alone is insufficient to change staff behavior sufficiently to change
client challenging behaviour (Cf. Shore, Iwata, Vollmer, Lerman, & Zarcone, 1995).
The finding that staff training had a specific effect on staff confidence is open to at
least two interpretations. First, the course specifically focused on teaching staff strategies to
deal with aggressive behavior in a more confident manner and directly focused on staff
fears when managing challenging behaviors. Thus, this particular form of staff training may
have a relatively specific effect on staff confidence. Earlier research on staff training in
Staff training and aggression
physical interventions has also found improvements in staff confidence (McDonnell, 1997;
Allen & Tynan, 2000).
The present course teaches staff a strategies that may be helpful with many clients.
However, individualization of training in physical interventions may be necessary (Allen,
2001). Perhaps a small number of service users may require highly customized plans for
physical intervention whereas a large number of staff and services users may benefit from
generic physical intervention training.
Training workshops alone may be necessary but not sufficient for behavioral change
to occur (Cullen, 1988.) should also may also need to be followed up in the workplace to
increase its effect. Shore et al (1995) demonstrated that a verbal in-service training course
explaining procedures to direct care staff was ineffective at changing staff behaviors related
to implementing behavioral interventions and client challenging behaviors. Thus, it may be
important to supplement staff training workshops, such as the one evaluated here, by
ongoing consultation and further staff training and support which involves practicing skills
with the client under supervision and whilst receiving feedback on implementation.
There were a number of limitations to this study. The use of a quasi-experimental
design may limit the confidence with which we can conclude that training caused a change
in staff confidence (Campbell & Stanley, 1963.) Future research should also focus on
variables that mediate staff confidence, such as staff fear and anger may be useful to
consider in future studies. The effect of training on staff behavior measured through direct
observation should also be addressed.
Staff training and aggression
Allen, D. (2000) Recent research on physical aggression in persons with intellectual
disability: An overview. Journal of Intellectual and Developmental Disability, 25,
Allen, D. (Ed., 2001) Training carers in physical interventions. Research towards
evidence-based practice. BILD: Kidderminster.
Allen D. & Tynan H (2000.) Responding to aggressive behavior: impact of training
on staff members' knowledge and confidence. Mental Retardation, 38, 97-
Campbell, D. & J. Stanley. (1963). Experimental and Quasi-Experimental Designs.
Chicago: Rand McNally.
Carr, E. G., Horner, R. H., Turnbull, A. P., Marquis, J. G., McLaughlin, D. M., McAtee, M.
L.,Smith, C. E., Ryan, K. A.,Ruef, M. B., Doolabh, A. Baddock, D. (1999). Positive
Behavior Support for People with Developmental Disabilities: A Research
Synthesis. Washington, DC: American Association on Mental Retardation.
Cullen, C. (1988.) Review of staff training: The emperors old clothes. The Irish journal of
Psychology, 9, 309-323.
Dagnan, D, (2002.) Personal communication.
Didden, R., Duker, P.C. & Korzilius, H. (1997) Meta-analytic study on treatment
effectiveness for problem behaviors with individuals who have mental retardation.
American Journal on Mental Retardation, 101, 4, 387-399.
Staff training and aggression
Emerson, E. (2002.) The prevalence of use of reactive management strategies in
community-based services in the UK. In: D. Allen, (Ed. ) Ethical approaches to
physical interventions. Responding to challenging behavior in people with
intellectual disabilities, (pp15-30.) Plymstock: BILD Publiscations..
Feldman, M. A., Atkinson, L., Foti-Gervais, L. & Condillac, R. (2004.) Formal versus
informal interventions for challenging behaviour in persons with
intellectual disabilities. Journal of Intellectual Disabilities Research, 48, 60-68.
Hanson, R. H., Weisler, N. A., & Lakin, K. C. (2002.) Crisis prevention and response in
the community. Washington, DC: American Association on Mental Retardation.
Harris, J. (2002). Training on physical interventions: Making sense of the market. In: D.
Allen, (Ed. ) Ethical approaches to physical interventions. Responding to
Challenging behavior in people with intellectual disabilitie, (pp. 134-152.)
Plymstock: BILD Publications.
Harris, J., Allen, D., Cornick, M., Jefferson, A. & Mills, R. (1996) Physical interventions. a
policy framework. BILD/NAS: Kidderminster.
Harris P., Humphreys J. & Thomson G. (1994). A checklist of challenging behaviour: The
development of a survey instrument. Mental Handicap Research, 7, 118-133.
Harris, P. & Rose, J. (2002) Measuring staff support in services for people with intellectual
disability: the Staff Support and Satisfaction Questionnaire. Journal of Intellectual
Disability Research, 46, 2, 151-157.
Staff training and aggression
Hatton, C. & Emerson, E. (1995.) The development of a Shortened Ways of Coping Scale
for use with direct care staff in learning disabilities services. Mental Handicap
Research, 8, 237-251.
McDonnell, A. (1997) Training care staff to manage challenging behaviour: An evaluation
of a three-day course. British Journal of Developmental Disabilities, 43, 156-161.
McDonnell, A., Dearden, B. & Richens, A. (1991a) Staff training in the management of
violence and aggression: 1- Setting up a training system. Mental Handicap, 19, 73-
McDonnell, A., Dearden, B. & Richens, A. (1991b) Staff training in the management of
violence and aggression: 2- Avoidance and Escape Principles. Mental Handicap,
19, 109-112.
McDonnell, A., Dearden, B. & Richens, A. (1991c) Staff training in the management of
violence and aggression: 3- Physical Restraint. Mental Handicap, 19, 151-154.
McDonnell A.A. & Reeves S. (1996). The adoption of a non seclusion policy on a locked
ward for people with a learning disability: A description of the process. Nursing
Times, 92, 42-44.
McDonnell, A. & Sturmey, P. (1993) Managing violent and aggressive behaviours of
people with learning difficulties. In Jones, R.S.P. & Eayrs, C. (Eds) Challenging
Behaviours and Mental Handicap: A Psychological perspective. Kidderminster:
McDonnell, A. & Sturmey, P. (2000). The social validation of three physical restraint
procedures: a comparison of young people and professional groups. Research in
Developmental Disabilities, 21, 85-92.
Staff training and aggression
McDonell, A. A. & Sturmey, P. (in press.) Evaluation of a staff training course to manage
violent and aggressive behaviour. Journal of Applied Research in Intellectual
McDonnell, A., Sturmey, P. & Dearden, B. (1993) The acceptability of physical restraint
procedures for people with a learning difficulty. Behavioural and Cognitive
Psychotherapy, 21, 225-264.
McDonell, A. A., Waters, T. & Jones, D. (2002). Low arousal approaches in the
management of challenging behavior. In Allen, D. (2001) Training carers in
physical interventions. Research towards evidence-based practice, (pp. 104-113.)
BILD: Kidderminster.
Needham, I., Abderhalden, C., Zeller, A., Dassen, T., Haug, H.J., Fischer, J.E. & Halfens,
R.J.G. (in press a). the effect of a training course in aggression Management on
nursing students’ confidence and perception of aggression. Journal of Nursing
Needham, I., Abderhalden,C., Halfens,R.J.G., Dassen, T., Haug, H.J., & Fischer J.E. (in
press b) The effect of a training course in aggression management on mental health
nurses’ perception of aggression: A randomised controlled trial. Journal of
Psychiatric and Mental Health Nursing.
Needham, I., Abderhalden,C., Meer, R., Dassen, T., Haug, H.J., Halfens, R.J.G. & Fischer,
J.E. (in press c) The effectiveness of two interventions in the management of patient
violence in acute mental inpatient settings: Report on a pilot study. Journal of
Psychiatric and Mental Health Nursing.
Staff training and aggression
Phillips, D., & Rudestam, K.E. (1995). The effect of non-violent self defence training on
male psychiatric staff members: aggression and fear. Psychiatric Services, 43, 164
– 168.
Rice, M.E., Helzel, M.F., Varney, D.W. & Quinsey, V.L. (1985). Crisis Prevention and
Intervention training for psychiatric hospital staff. American Journal of Community
Psychology, 13, 289 – 304.
Rojahn, J., & Tassé, M. J. (1996). Psychopathology in mental retardation. In J. W.
Jacobson, J. A. Mulick (Eds.), Manual on mental retardation and professional
practice (pp. 147-156). Washington, D.C.: American Psychological Association.
Scotti, J. R., Ujcich, K. J., Weigle, K .L., Holland, C. M., & Kirk, K. S. (1996)
Interventions with challenging behavior of persons with developmental
disabilities: A review of current research practices. Journal of the Association of
Persons with Severe Handicaps, 21, 123-134.
Shore, B. A., Iwata, B. A., Vollmer, T. R., Lerman, D. C., & Zarcone, J. R. (1995).
Pyramidal staff training in the extension of treatment for severe behavior disorders.
Journal of Applied Behavior Analysis, 28, 323-332.
Van den Pol, R. A., Reid, D. H., & Fuqua, R. W. (1983). Peer training of safety-related
skills to institutional staff: Benefits for trainers and trainees. Journal of Applied
Behavior Analysis, 16, 139-156.
... Whilst training in physical interventions may well be a relatively commonplace response, the evidence for its effectiveness is limited. There have been claims made about a number of variables, including increased confidence (30)(31)(32)(33)(34), improved knowledge (30,35), reduction in staff and patient injuries (36), and reduction in staff illness. While government guidelines and local policies imply that physical interventions are used as a last resort (2), staff training may not always lead to reductions in their use. ...
... Studies took place in a variety of settings and with different population groups (see Table 1). Ten studies were carried out in adult psychiatric settings (43,46,47,(49)(50)(51)(52)(53)(54)56); three in adult learning disabilities settings (30,45,57); one in a service for older adults (55); and one in a service for adults with autism (34). Two studies took place in general hospitals (44,48), one of which was an Intensive Care Unit (ICU) (44). ...
... Craig and Sanders (45) examined multiple services provided by one organisation for children and adults with intellectual and developmental disabilities and psychiatric needs. Studies were conducted in a variety of locations, including the United States (43,45,46,48,49,56,57); Switzerland (47, 51, 52); United Kingdom (30,34); Canada (53, 54); Australia (50); Taiwan (44); and Norway (55). The number of participants in each study varied widely from thirteen (57) to 1,488 (43). ...
Full-text available
Background Restrictive practices are used frequently by frontline staff in a variety of care contexts, including psychiatric hospitals, children’s services, and support services for older adults and individuals with intellectual and developmental disabilities. Physical restraint has been associated with emotional harm, physical injury to staff and consumers, and has even resulted in death of individuals in care environments. Various interventions have been implemented within care settings with the intention of reducing instances of restraint. One of the most common interventions is staff training that includes some physical intervention skills to support staff to manage crisis situations. Despite physical intervention training being used widely in care services, there is little evidence to support the effectiveness and application of physical interventions. This review will examine the literature regarding outcomes of staff training in physical interventions across care sectors. Method A systematic search was conducted following PRISMA guidelines using Cochrane Database, Medline EBSCO, Medline OVID, PsychINFO, and the Web of Science. Main search keywords were staff training, physical intervention, physical restraint. The MMAT was utilised to provide an analytical framework for the included studies. Results and discussion Seventeen articles have been included in this literature review. The included studies take place in a range of care settings and comprise a wide range of outcomes and designs. The training programmes examined vary widely in their duration, course content, teaching methods, and extent to which physical skills are taught. Studies were of relatively poor quality. Many descriptions of training programmes did not clearly operationalise the knowledge and skills taught to staff. As such, it is difficult to compare course content across the studies. Few papers described physical interventions in sufficient detail. This review demonstrates that, although staff training is a ‘first response’ to managing health and safety in care settings, there is very little evidence to suggest that staff training in physical intervention skills leads to meaningful outcomes.
... Several forms of intervention have been proposed for reducing CB in people with ASD, including medications (Malone et al., 2005;Blankenship et al., 2010;McPheeters et al., 2011;Sawyer et al., 2014), behavioral interventions (Scotti et al., 1996;Didden et al., 2006;Machalicek et al., 2007Machalicek et al., , 2016Lydon et al., 2013;Fettig and Barton, 2014;Erturk et al., 2018;MacNaul and Neely, 2018;Weston et al., 2018;Inoue, 2019), cognitive/emotion-oriented interventions (Neal and Barton Wright, 2003;Zetteler, 2008;O'Neil et al., 2011;Cotelli et al., 2012;Subramaniam and Woods, 2012;Doyle et al., 2013), sensory stimulation/integration interventions (Lang et al., 2012;Barton et al., 2015;Case-Smith et al., 2015;Leong et al., 2015;Wan Yunus et al., 2015;Watling and Hauer, 2015), music therapy (Gold et al., 2006;Stephenson, 2006;Simpson and Keen, 2011;James et al., 2015;Fakhoury et al., 2017), psychosocial interventions (Seida et al., 2009;Reichow et al., 2013;Vanderkerken et al., 2013;Bishop-Fitzpatrick et al., 2014;Lim, 2019), communication training (Mirenda, 1997;Goldstein, 2002;Lequia et al., 2012;Walker and Snell, 2013;Gerow et al., 2018;Gregori et al., 2020), physical exercises (Eggermont and Scherder, 2006;Ogg-Groenendaal et al., 2014;Sorensen and Zarrett, 2014;Forbes et al., 2015;Bremer et al., 2016), and others (McDonnell et al., 2008;Tanner et al., 2015;Lindgren et al., 2016;Ferguson et al., 2019;Walker et al., 2021;Wahman et al., 2022). Despite the wide availability of intervention forms, no consensus has been reached concerning the global efficacy of any CB treatment in treating all the CBs types. ...
Full-text available
Background Most people with autism spectrum disorder (ASD) present at least one form of challenging behavior (CB), causing reduced life quality, social interactions, and community-based service inclusion. Objectives The current study had two objectives: (1) to assess the differences in physiological reaction to stressful stimuli between adults with and without high-functioning ASD; (2) to develop a system able to predict the incoming occurrence of a challenging behaviors (CBs) in real time and inform the caregiver that a CB is about to occur; (3) to evaluate the acceptability and usefulness of the developed system for users with ASD and their caregivers. Methods Comparison between physiological parameters will be conducted by enrolling two groups of 20 participants with and without ASD monitored while watching a relaxing and disturbing video. To understand the variations of the parameters that occur before the CB takes place, 10 participants with ASD who have aggressive or disruptive CBs will be monitored for 7 days. Then, an ML algorithm capable of predicting immediate CB occurrence based on physiological parameter variations is about to be developed. After developing the application-based algorithm, an efficient proof of concept (POC) will be carried out on one participant with ASD and CB. A focus group, including health professionals, will test the POC to identify the strengths and weaknesses of the developed system. Results Higher stress level is anticipated in the group of people with ASD looking at the disturbing video than in the typically developed peers. From the obtained data, the developed algorithm is used to predict CBs that are about to occur in the upcoming 1 min. A high level of satisfaction with the proposed technology and useful consideration for further developments are expected to emerge from the focus group. Clinical trial registration [ ], identifier [NCT05340608].
... Nevertheless, the study demonstrated that there was not any evidence of reduction of clients' challenging behavior. The analysis of this study showed that the training was effective only for the staff and their levels of confidence on handling aggressive behaviors (McDonnell et al., 2008). Based on Jahr (1998), staffs' priority is to improve individuals with developmental disabilities quality of life. ...
Full-text available
The mediator training is an important procedure of the applied behavior analysis. By providing an appropriate training to the mediator, the trainer can enhance the likelihood that the trainee will implement the intervention plan accurately. The purpose of this study was to operate mediator training to an instructor therapist to implement mand training to a 5-year old girl with autism spectrum disorder. Through this study we had to follow all the necessary steps of the mediator training and to collect data, through the behavior fidelity checklist and the staff satisfaction survey. The results demonstrated that the mediator implemented the steps accurately and she was also satisfied from the overall training that she received. Moreover, the interobserver agreement for the treatment fidelity, between the comparison of trainers and trainee’s checklist, demonstrated exact agreement of the implementation of the intervention.
... There has been a focus on improving outcomes for this vulnerable population within the tertiary care sector and within specialized intellectual disability/developmental disability (ID/DD) facilities through provider training (Kuriakose et al. 2018;Siegel et al. 2012;Siegel and Gabriels 2014). Research done in these settings has shown that specialized trainings for the ID/DD population have increased staff knowledge and confidence (McDonnell et al. 2008), altered staffs' coping methods and attributions of behavior (Berryman et al. 1994;Zijlmans et al. 2015), and decreased challenging behaviors (Allen et al. 1997;Smidt et al. 2007). While these results are encouraging, less attention has been paid to training staff in general medical settings, community settings, and child welfare systems (Brookman-Frazee et al. 2012;Dillenburger et al. 2016;McGonigle et al. 2014;Nicholas et al. 2016;Zwaigenbaum et al. 2016). ...
Full-text available
Caring for individuals with autism spectrum disorder (ASD) can be complicated, especially when challenging behaviors are present. Providers may feel unprepared to work with these individuals because specialized training for medical and social service providers is limited. To increase access to specialized training, we modified an effective half-day ASD-Care Pathway training (Kuriakose et al. 2018) and disseminated it within five different settings. This short, focused training on strategies for preventing and reducing challenging behaviors of patients with ASD resulted in significant improvements in staff perceptions of challenging behaviors, increased comfort in working with the ASD population, and increased staff knowledge for evidence-informed practices. Implications, including the impact of sociodemographic characteristics on pre/post changes, and future directions are discussed.
... Few studies (n = 4) used some form of experimental design that wouldpotentiallyallow conclusions about the benefits or effectiveness of supports and interventions Mawhood & Howlin, 1999;McDonnell et al., 2008;Smith et al., 2002). Two of these evaluated interventions to improve staff skills working with people with complex needs, many of them autistic, using before-after and between-groups comparisons. ...
Technical Report
Rapid scoping review on social care and support for autistic adults.
Developmental support agencies support many adults with intellectual disabilities in the community. Unfortunately, these adults often exhibit high rates of challenging behaviour, which present significant pressures on these service providers. Agencies need to develop effective means of increasing their capacity to provide quality support. Previous systematic reviews found that training staff in positive behaviour supports can improve outcomes; however, the factors facilitating training’s effects, long-term effectiveness, and outcomes for service users have yet to be determined. We conducted a scoping review of 98 journal articles and book chapters to develop a model for fostering capacity development drawing from Organizational Behaviour Management and Knowledge Translation theories. Some relevant factors include features of the inner and outer organizational contexts, training approaches (e.g., behavioural skills training & in-situ coaching), ongoing support and feedback. This model may lead to more effective and enduring treatment programs and improved support for adults with intellectual disabilities.
Full-text available
There is very little knowledge regarding autistic adult services, practices, and delivery. The study objective was to improve understanding of current services and practices for autistic adults and opportunities for improvement as part of the Autism Spectrum Disorder in the European Union (ASDEU) project. Separate survey versions were created for autistic adults, carers of autistic adults, and professionals in adult services. 2,009 persons responded to the survey and 1,085 (54%) of them completed at least one of the services sections: 469 autistic adults (65% female; 55% <35 years old), 441 carers of autistic adults (27% female; 6% <35 years old), 175 professionals in adult services (76% female; 67% in non-medical services). Top choices by autistic adults, carers or professionals for services best suiting their current needs were: residential services: “help in own home” (adults, carers of high independent adults, professionals), “fulltime residential facility” (carers of low independent adults); employment services: “job mentors” (adults, carers of high independent adults, professionals), “Sheltered employment” (carers of low independent adults); education services: “support in regular education setting” (all groups); financial services: financial support in lieu of employment (“Supplementary income for persons unable to have full employment” for adults, “full pension” for carers of low independent adults) or to supplement employment earnings for carers of high independent adults and professionals; social services: “behavior training” (adults) and “life skills training” (carers and professionals). Waiting times for specific services were generally < 1 month or 1–3 months, except for residential services which could be up to 6 months; most professionals were uninformed of waiting times (>50% responded “don’t know”). Five of seven residential services features recommended for autistic adults were experienced by <50% of adults. The knowledge of good local services models that work well for autistic adults was generally low across all services areas. The variation in services experiences and perceptions reported by autistic adults, carers, or professionals underscore the need to query all groups for a complete picture of community services availability and needs. The results showed areas for potential improvement in autistic adult services delivery in the EU to achieve recommended standards.
Full-text available
Dealing with challenging behaviour is a source of stress and burnout among teachers of children with special education needs. Functional Behavioral Analysis (FBA) is useful for prevention and management of challenging behaviour, but the evidence-base among special education teachers is limited in Sub-Saharan Africa. Twenty teachers were recruited from two special needs schools (10 from each school), with one school designated ‘intervention’ and the other ‘control’. Two sessions of group-based training on FBA were conducted in the intervention school for the 10 teachers. All participants completed the ‘Teacher Self Efficacy Scale’ and ‘Professional Quality of Life Scale’ at baseline and again two weeks after the last intervention session. The intervention group completed a post-intervention ‘Client Satisfaction Questionnaire’. Controlling for baseline scores, the intervention group scored significantly higher on Self-Efficacy [F (1,18)=8.95, p=0.009, partial eta squared=0.36], and lower on Burnout [F (1,17) = 9.82, p=0.006, partial eta squared=0.380]. The intervention group’s mean score on the Burnout subscale of PQOLS was more than one standard deviation lower than the control group after the intervention [(29.30(2.58) vs 34.11(4.01)]. All participants in the intervention group rated the programme as good or excellent and over three-quarters (77.7%) would recommend it to their peers. To our knowledge, this is the first study of FBA training for special education teachers in Sub-Saharan Africa. The programme showed promising effectiveness, good feasibility and was highly accepted.
Purpose The purpose of this study is to evaluate a conflict management training that used a communication competence perspective. This addresses whether the training had an impact on role conflict, conflict resolution skills, horizontal violence, burnout, turnover intention and perceptions of consumers. It also assessed staff perceptions of the training. Design/methodology/approach A mixed-method analysis was used using survey data from multiple time points along with focus group interviews. Findings The program decreased role conflict, horizontal violence and burnout among direct-care workers, whereas feelings of safety and perceptions of workers’ ability to protect themselves and others in aggressive situations increased. Furthermore, staff felt the training was useful and increased feelings of safety and empowerment at the study. Practical implications These findings suggest that conflict management training may need additional refresher sessions. Administrative planning is also needed to ensure training of all staff is trained in an adequate timeframe. Originality/value These results, although positive, are somewhat time bound. Therefore, the content of training and knowledge dissemination of conflict management training need additional research to ensure best practices.
Full-text available
Abstract: Preventing student dropout seems to be a big challenge for school systems. This becomes even more severe for students who display aggressive behaviour. Aggression in students is manifested in several ways such as being defiant, use of profane language, verbally and physically aggressive. Without intervention, these behaviours become an impediment to academic success and quite often put the student on high-risk category for later social problems, school exclusion school failure or drop out. Student aggression is further compounded in Kenya given that there are no special schools for students with Emotional and Behavioural difficulties. This means that the only option for their placement is in regular schools. The purpose of the present study was to investigate the use of cognitive behavioural strategies in managing aggressive behaviour displayed by students in secondary schools in Kakamega County. Target population was 351 teachers drawn from Kakamega County. Stratified random sampling technique was used to sample 106 teachers. Data was collected using a questionnaire and behaviour checklist. The result of the study indicates a significant relationship between the cognitive behavioural intervention and student retention in secondary schools. The finding has direct implication to provision and practice of education in secondary schools in Kenya. Efforts should be made to train teachers on the use of cognitive behavioral strategies in order to reduce dropout of students who display aggressive behaviours. Key words: Cognitive behaviour intervention, aggressive Behaviour, student dropout
Full-text available
If many people with disabilities are to experience the benefits of positive behavior support (PBS), personnel in human service settings must be well versed in the values and practices of this approach. We describe a curriculum and methodology used to train supervisors in aspects of PBS on a statewide basis. The curriculum incorporated values of person-centered planning, ecologically valid practices, and principles of adult learning in conjunction with competency- and performance-based training. Selected components of the curriculum were initially evaluated experimentally with 12 supervisors. Observations during role-play activities and on-the-job applications indicated that the supervisors acquired the skills addressed in the training. Subsequently, the entire curriculum, which targeted 26 sets of skills related to PBS and involved 4 days of classroom training and 1 day of on-the-job training, was implemented with 386 supervisors across the state of South Carolina. Eighty-five percent of the supervisors successfully completed the training by demonstrating pre-established mastery-level performance for each set of skills. Acceptability measures suggested that all the trainees found the training useful, and 99.6% reported that they would recommend the training to other personnel. Results of the project are discussed in terms of the importance of training supervisors as one component of a systems-change process to enhance the practice of PBS on a large-scale basis.
An edited book of case studies of programs providing behavioral crisis prevention and response services to individuals with developmental disabilities living in home and community settings.
Challenging behaviour among people with learning disabilities is an area of increasing concern to service providers. Despite this concern there is little information available about how these behaviours should be managed. This paper presents pilot data on a three day training course which aimed to train staff to manage challenging behaviour. It was found that course participants acquired physical management skills such as physical restraint, and there were significant improvements in measures of knowledge and self confidence after training. The implications of these findings were discussed.
The first article in this series emphasised the setting conditions required for staff training in the management of violence and aggression. This second article presents strategies for avoidance and escape in the management of potentially violent situations using non-violent methods. One simple, non-violent method is illustrated.
Physically aggressive behaviours pose major problems to carers supporting people with intellectual disability. This review considers the prevalence and nature of this form of challenging behaviour within this population and describes possible causal factors. The present status of both behavioural and pharmacological interventions for aggression are assessed, and the importance of devising reactive management plans for aggressive behaviours outlined. Implications for future practice are discussed.
Discusses studies on the effectiveness of training caring staff to implement therapeutic procedures with mentally handicapped clients. An ecological approach to staff training suggests that staff training should be accompanied by changes in staff management and organization to improve the quality of life of clients. Studies involving procedures such as modeling, role-playing, and feedback as training methods are discussed. Characteristics common to intermediate (appropriate) technologies of staff training (e.g., effectiveness, expense, centralization) are identified. Open learning and personalized systems of instruction are also considered as methods of staff training. (PsycINFO Database Record (c) 2012 APA, all rights reserved)