Sheffield Health & Social Care Trust . . . always striving for the best 1

Sheffield Health & Social Care NHS Foundation Trust

Challenging Behaviours-

Where next for our services?

Dr Alick Bush

Clinical Director, Sheffield Health & Social Care Trust

9 June 2010

Alick.bush@shsc.nhs.uk

One minute synopsis

• There are still too many people in inappropriate Out of Area placements as a consequence of the inability of local services to understand their challenging behaviour

• Many have a poor quality of life and do not receive the specialist support they have been promised

• Failure to provide this locally is a waste of our precious resources

• Research literature shows what we should be doing to break this vicious cycle

• So what should we be doing?

Why is it important to get it right?

“Commissioning person-centred, cost effective, local support for people with learning disabilities (SCIE Knowledge

Review 20)” July 2008

www.scie.org.uk

What is known about the use of out of area placements (numbers, reasons for use), their quality and impact?

Out-of-area placements

• In 2006, over 11,000 people with a learning disability were placed out of area

• This is 34% of all people with a learning disability who are in Registered care

• Numbers range from 63% (inner London) to 24% Yorkshire and Humberside

• Most likely people:– CB, ASD, Mental Health, complex health, epilepsy, risk of

offending

Main reason?- nothing suitable is available locally

Problems with Out of Area placements

For the person

• Maintain contact with family• Hard to become part of life in

new area• New placement might not suit

person’s culture or experiences

• Little if any ‘checking’ from their home authority

• Residential schools- hard to plan for future move to adult provision

Service delivery

• Development of new institutions

• 76% had no PCP• 87% had no HAP• Congregate settings• Low level of access to

psychology, psychiatry, behavioural support

• Low engagement in community activities

• More expensive than locally based services

• Big problems for receiving authority

1. Inadequate local provisionfor people who challenge

3. Flow of ££’s from local services

4. Inadequate local provision for people who challenge

5. Increased numbers ofpeople who challenge

2. Need to purchase Out-of-area place

Spiral of lost resources to local services

What does the literature tell us, & what are implications for local partnership working?

1. Effectiveness of behavioural approaches2. Positive Behavioural Support (PBS)3. Uptake of effective behavioural approaches4. Person-centred planning/ approaches5. Function-based interventions6. Physical health7. Breakdown of community placements8. Congregate settings9. Assessment and Treatment Units10. Importance of front line staff

1. Psychologically-based approaches

• Best treatment outcomes happen when you have tried to understand why the behaviour occurs before you start to intervene- functional analysis (Grey & Hastings, 2005; Scotti et al, 1991; Didden et al, 1997, 2006)

Service users should have access to range of staff who are able to understand CB as functional,

and deliver interventions that take account of its likely function

F.A. approaches should be used alongside other types of intervention

2. Positive Behavioural Support (PBS)

• Goal of enhanced Q of L, not just behaviour change• Improved Q of L is intervention & outcome measure• Establish purpose of behaviour (function) for person• Focus on triggers for behaviour• Development of new skills is key• Long-term focus and maintenance plans• CB is multiply determined, so multiple interventions• Non-punitive strategies• Combine proactive and reactive risk management

strategies

Use of PBS in services

• Positive Behavioural Support is effective, shows long-term maintenance, and generalises across settings (Carr et al, 1999)

Service models should be designed on the principles of PBS

We must develop a culture of routine evaluation of range of outcomes that include Q of Life

3. Current uptake of behavioural approaches

• Low use of behavioural technologies & high use of anti-psychotics in residential settings (Robertson et al, 2005)

• Where they are used, it is usually informal (Feldman et al, 2004)

• When systematic staff training in Applied Behavioural Analysis and development of behavioural support plans is introduced, 77% of people showed reduction by 70%, maintained for 2 years (McClean et al, 2005).

Training in PBS/ABA must be built in and maintained systematically

Anti-psychotics should not be used to manage behaviour

4. Use of Person-centred planning

• Better quality of life outcomes & relocation to community for people receiving PCP (Holbourn et al, 2004)

• Valuing People Research Initiative- PCP gives better outcomes for those who receive it, but excluded groups are those with: CB, MI, communication difficulties, additional health problems

People with complex needs (including CB) should be priority for PCP, not the last in the queue.

5. Function-based interventionsInterventions that are based on understanding “what is the

purpose of this behaviour for the person?” and hence “how can we support the person to achieve the same goal, but without the need to use CB?”

• Function-based interventions (eg FCT) are repeatedly shown to be highly effective, but often poor generalisation (Schindler & Horner, 2005)

• Prevalence studies show ‘escape’ or ‘task avoidance’ is the most common function of CB (Hanley et al)- FCT can result in task avoidance!

Good PCP’s and communication passports are essential

Need to actively reinforce development of incompatible behaviours- promote engagement of activities

6. Role of general health

• Death By Indifference• Importance of discomfort as a ‘setting event’ (Regnard et

al, 2007)• Association between pain and SIB in Cornelia de Lange

syndrome (Moss & Oliver)- gastroesophageal reflux

Good health screening, maintenance of health, Health Action Planning, use of pain/distress tools (eg

DisDAT), communication passports, care pathways with general health

Increased investigation of behavioural phenotypes- biology/environment interface

7. Factors affecting breakdown of community placements

Broadhurst & Mansell (2007)- study of homes where places had broken down v not broken down:– Good written guidance and intervention programmes– Staff supervision– Post-incident de-brief

Those who select and fund placements should attend to the technical competence of the placement- can they do what they claim?

8. Use of congregate settings

• They generally cost more, make greater use of anti-psychotic medication and the use of physical restraint is higher than non-congregate

Non-congregate (ie minority of residents show challenging behaviour) accommodation should be commissioned in community

settings close to home

Need greater incentives to support people to stay in home county

9. Assessment & Treatment Units• The HCC audit!!!• Findings from 44 NHS areas (Mackenzie-Davies &

Mansell, 2007):– Only 40% had discharge plans– Inappropriate admissions– Bed blocking– Poor relationships with other services– Hard to recruit & retain staff– Poor environment & location– Mix of residents

• But…Asmus et al (2004)- short term highly specialist inpatient service- 66% showed reduction of 90%

ATU’s need very clear purpose, explicit part of stepped-care model, highly specialist training in

ABA++, with multi-disciplinary inputs

10. Front line staff as change agents

• Active Support (Stancliffe et al (2007); Beadle-Brown; Jones) leads to increased :– Staff : resident engagement– Community participation– Skills acquisition– Engagement in activities

• Staff practices are mediated by front-line supervision

Develop competencies of local leaders

Clarify- what do staff believe they are expected to do?

Use competency-based training models (Allen et al, 2008)

Encourage active development of practice leadership- build in quality (eg Periodic Service Review- LaVigna)

Public Health

Dept of Health website:“Public Health is concerned with improving the health of the

population, rather than treating the diseases of individual patients”

“If public health responsibilities are neglected it may be many years before the consequences can be seen; there is no immediate crisis. Of course there will be serious damage in the long-term but that could be 10 or 20 years in the future. Persuading any health system, whether in this country or elsewhere, to concentrate on the deep-seated causes of ill health is more difficult when the immediate pressures are so intense.”

Example of a Public Health approach- Tobacco (6 strands)

106,000 deaths per year in UK9 million adults in UK still smoke1. Smoke-free public places2. Reduce exposure to second-hand smoke3. NHS Stop Smoking Service4. Media/ education campaigns5. Regulate availability & supply- taxes6. Reduce tobacco advertising & promotion

A ‘Public Health’ approach to service design

• CB is often conceptualised as an individual problem requiring assessment & intervention, but must include prevention and long term reduction in prevalence (RCPsych, 2007; McGill; Emerson)

• Analogy with tobacco or crime. Aim to ‘design’ it out.

Apply to challenging behaviour:

Sophisticated PCP approach to tailor environment to person’s unique characteristics

Design-in individualised service supportsLess individually-focused strategies, more care

system-focused strategies

Step 5: Refer onto non community based intervention that is not available in Joint LD service:

-Secure provision-Forensic etc

Step 4: Refer onto local Intensive Support Service-more specialist/ detailed assessments-intensive interdisciplinary input in local community setting-access to local inpatient care

Step 3: Refer on for more detailed multi-disciplinary input eg-CLDT, ophthalmology, neurology, communication assessment- Multi-disciplinary working → team formulation→ A joined up shared understanding of person’s needs & how best to support them

Step 2: Easy access to uni-professional assessment & advice from psychology assistant, nurse, behavioural assistant etc:

-Assessment checklists-→ A shared understanding of person’s

needs and the most likely way that they need to be supported

Step 1: Universal self-help processes and information for service providers/ carers-Basic health needs addressed in primary care; Health Action Plan-Positive Behaviour Support Consultation-Basic risk management -Is provider service able to do what they need to do?-Self help guidance/ leaflets-High quality person centred plans addressing communication, likes/dislikes, ‘what makes a good day’ etc

Challenging Behaviour: a unified approach

RCPsych, BPS & RCS&LT (2007)

• Promotes a multi-disciplinary bio-psycho-social approach

• Guidance for best practice, built upon evidence-base

• Aims to design in best support

• 23 standards for service self-evaluation (RAG rating system and action planning)

11 clinical standards

1. Operate in current legal framework2. Documented risk assessments3. Written MD assessments4. Written integrated formulation5. Interventions use person centred approaches6. Written intervention plan7. Crisis management plans in place8. Effective care coordination9. Trained support staff10. Evaluate outcomes of interventions across broad

range11. Auditing of standards of care/interventions

12 Service standards

12. Equality of access to local provision13. Full range of services available14. Competence of services matches people’s needs15. Out of area placements reflect individual choice16. Commissioned services support people locally17. Access to local MD specialised advice18. Access to highly specialised advice for most complex19. Appropriate use of ATU’s20. Availability of local MH services21. Person centred planning in place22. Process to review people who are out of area23. Agreed commissioning strategy in place

Conclusions

• Aim to re-invest current Out if City expenditure into local services

• Take a Public Health approach to build-in effective approaches: this is likely to involve fundamental re-design in many areas, building upon current evidence-base

• Positive Behavioural Support should be the preferred service model

• How do you translate the standards into local practice for staff at the sharp end?

Brief References• RCPsych, BPS & RCS&LT (2007). Challenging Behaviour: a unified

approach. RCPsych.• Holburn et al (2004). The Willowbrook Futures Project. AJMR, 109,

63 – 76.• Grey & Hastings (2005). Evidence based practice in ID and

behaviour disorders. Current Opinion in Psychiatry, 469 – 475.• McClean et al (2005). Person focussed training. JIDR, 340 – 352.• Carr et al (1999). Positive Behavior Support: a research synthesis.

AAMR.• Feldman et al (2004). Formal versus informal interventions for CB.

JIDR, 60 – 68.• Robertson et al (2004). Quality and cost of community based

residential services. AJMR, 332 – 344.• Asmus et al (2004). Use of short-term inpatient model to evaluate

aberrant behaviour, JABA, 283 – 304.

References cont.

• Schindler & Horner (2005). Generalised reduction of problem behaviour of young children. AJMR, 36 – 47.

• Hanley et al (2003). Functional analysis of problem behaviour. JABA, 147 – 185.

• Peck Peterson et al (2005). Blending FCT and choice making. Educ Psychol, 257 – 274.

• Regnard et al (2007). Understanding distress in people with severe communication difficulties . JIDR, 277 – 292.

• Broadhurst & Mansell (2007). Organisational and individual factors associated with placement breakdown. JIDR 293 – 301.

• Mackenzie-Davies & Mansell (2007). Assessment & Treatment Units: an exploratory study. JIDR, 802 – 811.

• Stancliffe et al (2007). Implementation & evaluation of Active Support. JIDR, 446 – 457.

• Allen et al (2008). Using e learning to develop service-wide competencies. Tizard LD Review 3 – 9.