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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: www.cndd.Bham.ac.uk E-mail: cndd-enquiries@contacts.bham.ac.uk
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Staff training and aggression
Abstract
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.
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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
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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
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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
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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.
Method
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
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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.
Measures
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
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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
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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.”')
Design
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-
tests.
Procedure
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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.”
Results
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
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Staff training and aggression
the experimental group (p's < .01). Thus, staff training had an effect on staff confidence
scores.
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.
Discussion
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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
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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.
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Staff training and aggression
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