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Low arousal approaches to manage behaviours of concern.
Abstract
Testing the validity and reliability of a new measure of low arousal.
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This article explores the ethicolegal and political factors associated with physical restraint in intellectual disability practice in Ireland.
The primary purpose of physical restraint in intellectual disability care is to prevent injury or harm to the service user or others, yet research evidence shows it can cause trauma and injury. Physical restraint is a controversial topic and it is important for nurses to remain up to date with clinical governance strategies, regulation and policy developments.
In recent years, there has been debate regarding the use and misuse of the restrictive practice of physical restraint, particularly in care settings where vulnerable clients reside. In intellectual disability services, nurses face difficult decisions in caring for clients when managing challenging behaviour.
The protection and safety of the service user is of utmost importance and includes: legal considerations regarding professional duty of care and consent; political matters of advocacy and power; human rights; and ethical principles.
Ethics require a moral approach that ‘first does no harm’, engaging in beneficial practices that serve to uphold the best interests of service users and engender public trust.
This article is the second in a two-part series. Heyvaert et al. focused on the effectiveness of restraint interventions (RIs) for reducing challenging behaviour among persons with intellectual disabilities) in the first article. In this second article, Heyvaert et al. focus on experiences with RIs for challenging behaviour among people with intellectual disabilities.
A mixed methods research synthesis involving statistical meta-analysis and qualitative meta-synthesis techniques was applied to synthesize 76 retrieved articles. This second article reports on the qualitative meta-synthesis of 17 articles on experiences with RIs for challenging behaviour among people with intellectual disabilities.
The 17 included articles report on important variables relating to the persons receiving RIs, to the persons giving RIs and to their interactions and relationship, as well as variables situated at the meso- and macro-level.
The developed model can assist in reflecting on and improving of current RI practices among people with intellectual disabilities.
Positive behaviour support emphasises the impact of contextual variables to enhance participation, choice, and quality of life. This study evaluates a sequence for implementing changes to key contextual variables for 4 individuals. Interventions were maintained and data collection continued over a 3-year period.
Functional assessments were conducted with 4 individuals with exceptionally severe challenging behaviours. Interventions were based on the multi-element model of behavioural support (LaVigna & Willis, 2005a). Dependent variables were behavioural ratings of (1) frequency, (2) episodic severity, (3) episodic management difficulty, and measures of (4) mental health status, and (5) quality of life. The intervention sequence was low arousal environment, rapport building, predictability, functionally equivalent skills teaching, and differential reinforcement strategies.
Substantial reductions in target behaviours were observed, along with incremental improvement in mental health scores and quality-of-life scores.
The study demonstrates the efficacy of positive behaviour support for people with exceptionally severe behaviour in individually designed services.
A meta-analysis of prevalence and cohort studies conducted over the last 30 years was carried out to identify risk markers for challenging behaviour shown by individuals with intellectual disabilities (IDs). A total of 86 potential studies was identified from the review, with 22 (25.6%) containing sufficient data to enable a statistical analysis to be conducted. Results indicated that males were significantly more likely to show aggression than females, and that individuals with a severe/profound degree of ID were significantly more likely to show self-injury and stereotypy than individuals with a mild/moderate degree of ID. Individuals with a diagnosis of autism were significantly more likely to show self-injury, aggression and disruption to the environment whilst individuals with deficits in receptive and expressive communication were significantly more likely to show self-injury. In most cases, tests for heterogeneity were statistically significant, as expected. The meta-analysis highlighted the paucity of methodologically robust studies of risk markers for challenging behaviours and the lack of data on incidence, prevalence and chronicity of challenging behaviour in this population.
The authors examine the facet structure of mindfulness using five recently developed mindfulness questionnaires. Two large samples of undergraduate students completed mindfulness questionnaires and measures of other constructs. Psychometric properties of the mindfulness questionnaires were examined, including internal consistency and convergent and discriminant relationships with other variables. Factor analyses of the combined pool of items from the mindfulness questionnaires suggested that collectively they contain five clear, interpretable facets of mindfulness. Hierarchical confirmatory factor analyses suggested that at least four of the identified factors are components of an overall mindfulness construct and that the factor structure of mindfulness may vary with meditation experience. Mindfulness facets were shown to be differentially correlated in expected ways with several other constructs and to have incremental validity in the prediction of psychological symptoms. Findings suggest that conceptualizing mindfulness as a multifaceted construct is helpful in understanding its components and its relationships with other variables.
Objectives: Understanding predictors of burnout could potentially aid interventions for staff working in services for people with intellectual disabilities (ID). This study sought to understand predictors of burnout for staff specifically focusing on the moderating effect of emotional intelligence (EI) and self-efficacy. Methods: Eighty-six staff members working in services for people with ID completed a series of questionnaires about their experiences of violence, burnout [emotional exhaustion (EE), depersonalization (DP), and reduced personal accomplishment (PA)], self-efficacy, and EI. Results: Exposure to violence and low self-efficacy predicted EE and DP. Self-efficacy moderated the relationship between exposure to violence, DP, and EE. Emotional intelligence predicted PA. Emotional intelligence did not moderate the relationship between violence and burnout. Conclusions: Self-efficacy may potentially protect individuals from the development of burnout while working in services for people with ID. Further research is needed into the utility of the construct of EI and exploring the role of staff EI in the context of services for people with ID.
A broad range of factors have been identified as having an impact on burnout and performance. To improve our understanding of how these factors interact, a model of carer stress is tested. Staff were surveyed in residential units, assessments included burnout, organizational factors, staff cognitions and ratings of resident challenging behavior. The relationship between challenging behavior and emotional exhaustion was fully mediated by fear of assault. The relationship between emotional exhaustion and experienced safety (an organizational variable) was also fully mediated by fear of assault. The use of the model with staff is supported and it suggests that staff burnout can be reduced by influencing either staff cognitions, organizational factors or challenging behavior or a combination of these factors.
Background The use of physical restraints has generated immense controversy in the delivery of services to individuals with intellectual disabilities. The current zeitgeist is that effective positive approaches obviate the need for using physical restraints. In a multiple baseline design, we sought to assess how training staff members in mindfulness affected their use of physical restraints for aggressive and destructive behaviours of individuals with intellectual disabilities.
Methods Twenty-three members of staff working in four group homes participated in a 12-week mindfulness-training programme. Objective data were collected on the number of incidents, staff observations of incidents, staff verbal redirections, restraints used, Stat medications administered, staff injuries and peer injuries. Data were collected during baseline, mindfulness training and mindfulness practice phases.
Results As mindfulness training progressed, the use of restraints decreased, with almost no use being recorded by the end of the study. Any use of physical restraints was correlated with new admissions and on-call staff who had not received training in mindfulness. Stat medications administered also decreased and staff and peer injuries were close to zero levels during the latter stages of mindfulness practice.
Conclusions Data from this initial study suggest that staff training in mindfulness is potentially beneficial to both staff and the individuals with intellectual disabilities, particularly in reducing the use of physical restraints and Stat medication for aggressive and destructive behaviours.
Background An important question in community living is what factors influence the extent to which staff provide ‘active support’.
Methods Engagement, care practices and a range of staff and organizational characteristics were studied in 72 residential homes serving 359 adults with intellectual disabilities. Managers in 36 settings were trained in person‐centred active support (PCAS). A group comparison design and multivariate analysis was used to investigate the relationship between variables.
Results The PCAS group showed more active support, assistance, other contact from staff and engagement in meaningful activity but no difference in choice‐making or assessment of participation in activities of daily living. The PCAS group had more staff with a professional qualification, were more likely to think that challenging behaviour was caused by lack of stimulation, had attitudes more in line with a policy of community care, rated most care tasks as less difficult, and were more organized to deliver active support. The comparison group were more likely to think that challenging behaviour was learned negative behaviour, showed more teamwork and were more satisfied. Multivariate analysis identified a range of staff and organizational variables associated with engagement and active support.
Conclusions The results suggest that some variables which have not hitherto been studied in relation with active support are associated with it. Professional qualification, knowledge and experience appear to be important as do some staff attitudes, clear management guidance, more frequent supervision and team meetings, training and support for staff to help residents engage in meaningful activity.
Introduction Attribution theory posits that helping behaviour is determined in part by the potential helper’s attributions and emotions regarding the behaviour that requires help. Specifically, helping is considered to be more likely if stability is perceived as low, generating optimism for change, and if controllability is perceived as low, engendering high levels of sympathy and low levels of anger.
Method We conducted a systematic literature search to identify studies that have tested these predictions in relation to carers’ propensity to help people with intellectual disabilities who display challenging behaviour.
Results The literature is inconsistent and provides at best partial support for the theory. This situation differs from that seen in the general population, where the predictions of attribution theory are broadly supported.
Discussion We consider three potential explanations for this discrepancy: the reliability of the largely vignette‐based methodology, the fact that most studies fail to define ‘helping’ explicitly and the possibility that attribution theory might apply only to low‐frequency behaviours.
Recently, the Staff-Client Interactive Behavior Inventory (SCIBI) was developed, measuring both interpersonal and intrapersonal staff behavior in response to challenging behavior in clients with ID. The aim of the two studies presented here was first to confirm the factor structure and internal consistency of the SCIBI and second to demonstrate its convergent validity. In the first study, a total of 265 support staff members, employed in residential and community services, completed the SCIBI for 62 clients with ID and challenging behavior. In the second study, 158 staff members completed the SCIBI for 158 clients, as well as the SASB-Intrex, the NIAS and the Bar-On Emotional Quotient Inventory (EQI). Replication of a confirmatory factor analysis resulted in a consistent seven-factor solution of the SCIBI with high levels of internal consistency. Also, mostly good convergent validity with the SASB-Intrex and sufficient to good convergent validity with the NIAS and EQI were found, except for the self-reflective intrapersonal staff behavior scale. By replicating and extending earlier results on the SCIBI, it proves to be a reliable and sufficient valid measure of interpersonal and intrapersonal behavior of staff working with people with intellectual disabilities.
A gap prevails between the conceptualization of good practice in challenging behaviour management and its implementation in intellectual disability services. This study aimed to investigate staff members' perspectives of managing clients with challenging behaviours in residential services.
Semi-structured interviews were conducted with eleven staff in two services. Additionally, service documents on challenging behaviour management were examined in these services. A qualitative methodology was used to investigate staff members' immediate responses to clients' difficult behaviours and their decision-making processes.
The immediate responses of staff were conceptualized as the result of complex appraisals shaped by their service context involving the core processes of making the right choice and prioritizing the best interests of all involved.
Staff members' responses were understood as a dynamic and retroactive process, where their past and current challenging behaviour management experiences in the service influenced their responses to clients in the future.
The main goal of this study was to investigate whether staff members vary in their frequency reports on challenging behaviour concerning the same client. Because staff's approaches of challenging behaviour are affected by a range of staff characteristics, we hypothesised that these staff characteristics could explain this variability between staff members. We used questionnaires to investigate the influence of staff's age, gender, experience in working with people with intellectual disabilities, working hours, professional qualifications, sort of education, and their emotional reactions and beliefs regarding the challenging behaviour. This study involved 152 staff members and 51 clients with severe or profound intellectual disabilities who displayed self-injurious behaviour, stereotyped behaviour, and/or aggressive/destructive behaviour. A part of the variability between staff's reports on the frequency of challenging behaviour was indeed explained by differences between the staff members. Working hours, internal attribution, gender, and experience in working with people with severe or profound intellectual disabilities turned out to be influencing variables. Summarising, staff members differ in their reports on the frequency of challenging behaviour. To get an accurate picture of a client's challenging behaviour, perceptions of several staff members are needed.
Challenging behaviours are frequently a problem for people with autism spectrum disorders (ASD) and intellectual disability (ID). A better understanding of which individuals display which behaviours, at what rates, and the relationship of these behaviours to comorbid psychopathology would have important implications.
A group of 161 adults with ASD (autistic disorder or Pervasive Developmental Disorder--Not Otherwise Specified [PDD-NOS]) and 159 matched controls with ID only residing in two large residential facilities in Southeastern United States, were studied using the Autism Spectrum Disorders--Behavior Problems for Adults (ASD-BPA).
In all four categories of challenging behaviour measured by the ASD-BPA (Aggression/Destruction, Stereotypy, Self-Injurious Behavior, and Disruptive Behavior), frequency of challenging behaviours increased with severity of autistic symptoms. The greatest group differences were found for Stereotypy (repeated/unusual vocalisations/body movements and unusual object play), Self-Injurious Behavior (harming self and mouthing/swallowing objects), Aggression/Destruction (banging on objects), and Disruptive Behavior (elopement).
Challenging behaviours in people with ASD and ID are barriers to effective education, training, and social development, and often persist throughout adulthood. Thus, programs designed to remediate such behaviours should continue across the life-span of these individuals.
Background Theoretical models and emerging empirical data suggest that the emotional reactions of staff to challenging behaviours may affect their responses to challenging behaviours and their psychological well-being. However, there have been few studies focusing on factors related to staff emotional reactions.
Methods Seventy staff working in educational environments with children with intellectual disability and/or autism completed a self-report questionnaire that measured demographic factors, behavioural causal beliefs, behavioural knowledge, perceived self-efficacy, and emotional reactions to challenging behaviours.
Results Regression analyses revealed that behavioural causal beliefs were a positive predictor, and self-efficacy and behavioural knowledge were negative predictors of negative emotional reactions to challenging behaviours. Staff with formal qualifications also reported more negative emotional reactions. No other demographic factors emerged as significant predictors.
Conclusions The results suggest that behavioural causal beliefs, low self-efficacy and low behavioural knowledge may make staff vulnerable to experiencing negative emotional reactions to challenging behaviours. Researchers and clinicians need to address these issues in staff who work with people with challenging behaviours.
Many aspects of the management of acutely disturbed behaviour have only relatively recently come under systematic scrutiny. Perhaps regrettably one of the last amongst the range of strategies that may be employed to be subjected to rigorous examination has been physical restraint. Considerable debate has recently taken place around what represents good practice in this sensitive and controversial area but the continuing dearth of research in some aspects of this area of practice has meant that this discussion has arguably been over reliant on 'expert' opinion. Questions continue regarding some fundamental issues of restraint, including the relative risks involved in alternative approaches, and anxieties have been expressed about the potential for injuries and death to result from restraint. This article outlines the results of a survey that sought to explore the incidence of deaths associated with restraint in health and social care settings in the UK. The outcome of an initial analysis of the cases identified is then discussed, with reference to the literature on restraint-related deaths, in order to identify the implications for practice.
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