Leading the way and reducing restrictive practice: BILD Positive Behaviour Support Conference

by Nessa Hughes, Behaviour Therapist, SCJMS Services, South Kildare

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The British Institute of Learning Disability (BILD) marked their tenth annual behaviour support event by hosting their first international conference for research and practice in Dublin on 6.7 May 2010- The aim of the conference was to examine the contribution of Positive Behaviour Support (PBS) to individuals with intellectual disabilities, specifically in reducing restrictive practices. Individuals with intellectual disability who may injure themselves or others are often at risk of having restricted opportunities and choices in their lives and they may be vulnerable to the use of physical interventions. In the past, BILD has focused on best practice in the use of physical interventions. This conference, however, aimed to promote the reduction of restrictive practices in services.

Keynote speakers examined the role of Positive Behaviour Support as the model to reduce aversive and restrictive practices to support those most vulnerable. Delegates heard from a wide range of experts from Europe, North America, Syria and Australia and 17 workshops offered the opportunity for discussion groups in a range of topics. A number of common themes emerged from the two days of presentations, including:
— the need for cultural change within services;
— training staff in core competencies;
— providing incentives for change to happen within services through leadership;
— promoting evidence-based practices; promoting a strategic plan regarding the reduction of restrictive practices;
— the need for services to remain focused on person-centred values: demonstrating effective outcomes for service users;
— the need for effective assessments and supports that address the complex needs of individuals with intellectual disability and challenging behaviours.

Dr Brodie Paterson, Director of CALM Training Services in Scotland, presented on Corrupted cultures of care. Corruption is defined as the betrayal of value systems an organisation purports to have. A characteristic of corrupted care organisations would be the use of coercive and restrictive practices. Dr Paterson described the types of social systems that are vulnerable to corruption, which include systems that dehumanise people; systems where inequality is evident, where there is a culture of compliance, or organisations where there is a lack of management and accountability. Dr Paterson concluded that in order to prevent such corruption, organisations need to remain focused on values and integrity, with a culture of respect which focused on the individuals in the service. He highlighted a need for strong leadership, and for services to promote evidence-based practices.

Dr Jeffrey Chan described his role as a ‘senior practitioner’ in Victoria, Australia; a role which involves protecting the rights of people with disability who may be vulnerable to the use of restraint. In Victoria there is a legislative drive to reduce restrictive practices over a 5-year period, and Dr Chan described the use of a proactive approach which offers practitioners ‘dignity grants’ of up to $2000, offered to reduce a reliance on aversive approaches by empowering frontline staff to promote solution.focused alternatives within organisations. Dr Chan described how seclusion rooms have been decommissioned and replaced by relaxation rooms or activity rooms. He noted that producing positive outcomes relies on a partnership being created between teams at a state level, which must then collaborate with staff at a local level, closing the gap between policy and practice.

Professor David Allen’s (Bro Morgannwg University, Wales) presentation focused on the difficulties in developing service-wide competencies to meet the complex needs of all people with challenging behaviour. He described how PBS projects implemented across ID services in Wales have demonstrated effective outcomes for service users and good evidence-based support practices. He made reference to the Mansell Report’s recommendations for well managed services to show commitment, individualisation, effective models of care and investment in relationships in order to meet the needs of individuals who have challenging behaviour. Professor Allen argues there is a need for local specialist services to contribute to practices within mainstream services. He discussed the need for behaviour change strategies and he outlined the benefits of a three-tiered national vocational qualification e.learning program which was funded by the Welsh Assembly government. This training program provides critical skills for staff supporting people with challenging behaviour, which includes modules in Person-centred active support, PBS, Total communication, Person-centred planning, and recognising and responding to mental health problems. Finally Allen proposed assessing outcomes of PBS at a larger scale to share good practices and develop a national perspective in PBS.

Dr Mickey Keenan, Senior Lecturer University of Ulster and fellow of the BPS, in his presentation Applied Behaviour Analysis: the Irish debate, highlighted the misinformation in Ireland regarding the science of Applied Behaviour Analysis (ABA). He emphasised the need for ABA practitioners to engage in meaningful discourse with politicians to dispel preconceived beliefs about ABA so that they may inform policy in evidence-based practices to improve the lives of children with autism.

As well as focusing on the need for cultural change within organisations, a number of keynote speakers explored the complexities of understanding the needs of individuals who engage in challenging behaviours. Rather than focusing solely on situational factors, there was consensus on the need for a broad analysis of the context in which behaviours occur.

Bob Bowen, Mandt Training (USA), described research on the prevalence of trauma experienced by people with intellectual disabilities and challenging behaviours. Bowen argued that trauma may have an impact on neurological development, causing that person to perceive the world differently from someone who had not experienced trauma. He proposed that traumatised individuals may be more vigilant to perceived threats in the world. Challenging behaviours then can be viewed as fear or anxiety responses to perceived threats. The impact of restraint on people experiencing fear or anxiety is likely to cause further trauma. Bowen asserted that integrating this knowledge into Positive Behaviour Support plans can enrich our understanding of why challenging behaviours may occur and can assist services to develop supports for people that avoid employing restrictive practices.

Sally Meadows, in a presentation entitled The self that Sally built, shared her experiences of mainstream educational placements, residential placements and mental health services before she received a diagnosis for autism and epilepsy. As she learned more about these ‘new labels’ she also learned to understand herself better and to get the supports she needed to live a better life.

Dr Andy McDonnell (Studio III) and Mr Mills’ (NAS) presentation focused on the types of supports needed for people with an autistic spectrum disorder (ASD). In understanding that people with autism experience the world differently, services can adopt Person-centred supports that are ‘autism friendly’. Drawing on research demonstrating differences in physiological responses and sensory processing experienced by people with autism, Dr approach. This approach focuses on the avoidance of confrontation and the employment of antecedent strategies, such as the removal of aspects of the environment that might trigger behaviours, in the management of challenging behaviours.

The speakers highlighted the need for services to understand the role of staffs’ behaviour in maintaining challenging behaviour. The SPELL framework was outlined as an evidence-based Person-centred approach for people with autism which recommends:
Structure – making the world predictable, increasing a person’s autonomy
Positive approaches and expectations – focusing on a person’s strengths
Empathy – understanding ‘autistic thinking’
Low arousal – applying the concept of low arousal, understanding sensory differences
Links – working towards a consistent response from staff.

Gary LaVigna, the Clinical Director of the IABA, closed the two-day conference with a presentation that focused on examining the meaning of behaviours beyond a simple analysis of antecedents and consequences. He outlined the implications of this type of analysis for the proactive and reactive strategies employed in supporting people with behaviours that challenge. LaVigna emphasised the need for more research to develop effective reactive strategies that may reduce the ‘episodic severity’ or the intensity of a behavioural incident without reinforcing or strengthening that behaviour. Research in this area might support the reduction of restrictive practices in services and minimise injury for service users and staff.
Following the first day of presentations, Dr Oussama Abdallah, a PhD Student at Northumbria University, received the Leader of the Future Award for his research project supported by the Syrian Ministry of Health, the World Health Organisation and UNICEF. He outlined plans for designing a national strategy to develop services and improve the quality of life for children and young people with autism and learning disabilities in Syria.

Tying together the central presentations of the conference, Sharon Paley, Development Manager for Positive Behaviour Support at BILD, outlined the third edition of the BILD Code of Practice and BILD’s plans for the year ahead. The emphasis has shifted from a focus on best practice in the use of physical interventions, where unplanned or unregulated use of physical interventions were of primary concern, to a human rights approach, challenging the use of these restraints altogether through positive behaviour supports. In developing a framework to support organisations to identify and reduce restrictive practices, BILD are proposing strategies to highlight good practice. One such strategy is to launch a Positive Behaviour Quality Award Scheme in July 2010 to assess services’ adherence to the standard of the Code of Practice.

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