Emerging trends in the use of drugs to manage the challenging behaviour of people with intellectual disability

Background Concerns about the pharmacological management of the behaviour of individuals with intellectual disability have resulted in the development of legislative and procedural controls.
Method This Australian study provided a comparison of 873 reported cases where drugs were administered to manage behaviour in March 2000, with 762 cases reported in March 1993. Drug use in individuals who remained medicated across time (n = 316: recurrent sample) was also compared with those who were reported only in 1993 (n = 329: limited sample).
Results A small decrease in the proportion of individuals who were reported to have received medication was evident over time (from 5% to 4.5% of total population). However, this was accompanied by an increase in drug diversity and interclass polypharmacy. An increase in antidepressant use was evident (from 7.4% to 13.8% of reported drugs), and there was a trend towards greater reporting of medication for acute behavioural problems and medication use with children. Greater use of antipsychotic drugs was evident in individuals who remained medicated across time compared with those who did not.
Conclusions The findings suggest the need for continuous research into practice. The fact that many individuals receive medication over long periods makes it incumbent on service providers to engage in regular, comprehensive and individualized review and evaluation of medication regimes.

Challenging behaviour profiles of people with acquired brain injury living in community settings

Primary objective: To determine the type and severity of challenging behaviours among a cohort of brain-injured persons referred to a community-based behaviour management service; and to determine whether different behaviour profiles were associated with aetiology of brain injury.
Methods and procedures: A sample of clients (n= 190) referred to the ABI Behaviour Consultancy for assessment and treatment of challenging behaviours was evaluated using the Overt Behaviour Scale (OBS) and other measures of disability and support needs.
Main outcomes and results: The most common challenging behaviour categories were, in order of frequency: verbal aggression, inappropriate social behaviours and lack of initiation. Clients typically exhibited four categories of challenging behaviour and multiple kinds of the behaviours represented by each category. There was some evidence of differences in occurrence of specific behaviours associated with aetiology of brain injury, particularly for hypoxia and alcohol-related brain injury.
Conclusions: A systematic assessment of challenging behaviours in community settings has revealed the profiles of broad behavioural disturbance that can occur following ABI. Assessing the breadth of disturbance is important in understanding a client's presentation and thus planning appropriate behaviour management interventions.

The effect of active support training on engagement, opportunities for choice, challenging behaviour and support needs

Background: The aim of this study was to evaluate active support (AS) training and to investigate changes to perceived engagement in domestic tasks, opportunities for choice, frequency of challenging behaviour, and level of support needs.

Method: Participants were 12 adults with ID aged 27–57 years (M = 37 years) residing in three group homes, and their support workers. The support workers completed assessments on three occasions (at baseline, post-training, and at follow-up).

Results: Residents' engagement in domestic tasks increased over time, and overall choice increased, although perceived choice in two life domains initially increased, but decreased to baseline levels at follow-up. Residents exhibited an overall decrease in anxiety, self-absorbed behaviour, disruptive behaviour, and problem behaviour in general. There was also an overall decrease in perceived support needs for five activity domains, with no change for one domain.

Conclusions: The results contribute to a growing body of evidence demonstrating favourable outcomes of AS in terms of engagement and challenging behaviour in people with ID. Surprising results are presented for choice and perceived support needs, warranting further investigation.

The overt behaviour scale (OBS): a tool for measuring challenging behaviours following ABI in community settings

OBJECTIVES: The Overt Behaviour Scale (OBS) was designed as a comprehensive measure of common challenging behaviours observed after acquired brain injury (ABI) in community settings. The OBS comprises 34 items in nine categories that measure aggression, inappropriate sexual behaviour, perseveration, wandering, inappropriate social behaviour and lack of initiation. The aim of the current study was to determine the reliability, validity and responsiveness of the OBS. METHOD: Two adult community-based samples of people with ABI were recruited. Sample 1 (n= 30) were concurrently evaluated on the OBS by two raters and again 1 week later to test stability. Other validating scales were also administered. Sample 2 (n= 28) were clients of the ABI Behaviour Consultancy who were treated for challenging behaviours and were administered the OBS before treatment commenced and then again 4 months later. RESULTS: Inter-rater reliability and stability coefficients for the OBS total score was strong (0.97 and 0.77, respectively). Initial evidence of convergent and divergent validity was shown by the differential pattern of correlations with other measures. Moderate-to-strong coefficients (range 0.37-0.66) were observed between the OBS and other measures that had behavioural content (i.e. Mayo-Portland Adaptability Inventory, Current Behaviour Scale, Neurobehavioural Rating Scale-Revised). Divergent validity was shown by the lack of correlation between the OBS and the sub-scales of these tools that do not measure challenging behaviour. Finally, responsiveness was demonstrated with a significant decrease in OBS scores in the expected direction over the 4-month period. This improvement was confirmed by corroborating evidence from key informants. CONCLUSION: The OBS shows promise as a reliable, valid and responsive measure that can be used for the systematic assessment of challenging behaviours in community settings.

The relationship between residence and the pharmacological management of challenging behavior in individuals with intellectual disability

Many individuals with intellectual disability are administered psychotropic drugs to manage their challenging behavior. The increased relocation of individuals from institutions into community-based accommodation during the past decade provides an opportunity to examine the relationship between setting and drug administration. This study provides acomparison of drug use according to the type of residential facility of 873 individuals reported to have been administered drugs for behavioral restraint in March 2000, with 762 individuals reported in March 1993. In 2000, individuals in institutions were reported toreceive a moderately greater number of drugs concurrently than those in the community. However, there were no differences in the proportion of individuals prescribed drugs relative to the total population living in the respective settings. This is in contrast to the findings from 1993, where drug use was greater in individuals who were living in institutions. It was also more common for individuals who continued to be medicated across time to have previously lived in an institution. Although relocation into the community may be associated with improved living conditions, it is important to recognize that this change in living conditions is not necessarily associated with less use of drugs to manage behavior.

Assessing behaviour support plans for people with intellectual disability before and after the Victorian Disability Act 2006

Background : This study sought to elucidate the extent to which behaviour support plans for people with intellectual disability are inclusive of best practice criteria, with a comparison made prior to and following proclamation of the Disability Act (2006) in Victoria, Australia.

Method : This study used a data collection instrument developed by the researchers incorporating best practice criteria as identified in the review of literature and Victorian legislative requirements. The instrument was used to assess a sample of behaviour support plans.

Results : Best practice criteria are inadequately included in behaviour support plans with little difference between pre- and post-Act plans.

Conclusion : The results of this study indicate that disability support staff are ill equipped to undertake the complex assessments, planning, and implementation associated with behaviour support strategies, despite the legislative framework that guides and directs this intervention

Restrictive interventions for people with a disability exhibiting challenging behaviours : analysis of a population database

Background: People with an intellectual disability whose behaviours are perceived to be of serious harm to themselves or others are at risk of being subjected to restrictive interventions. Prevalence rates are difficult to determine, as most research is unable to draw on the results of population-level data.

Method: The current study reports on the use of chemical and mechanical restraint and seclusion in the State of Victoria, Australia, over a 12-month period.

Results: The majority of people included were subjected to chemical restraint. The use of restraint was found to be routine rather than a strategy of last resort. Consistent with findings in the UK and USA, those subjected to restrictive interventions were more likely to be young males with multiple disabilities, including autism.

Conclusions: Systemic policy and procedural developments are needed to address current use of restrictive interventions, together with a longitudinal study to evaluate the effectiveness, of alternative, non-restrictive strategies.

Factors influencing quality of behaviour support plans and the impact of plan quality on restrictive intervention use

Background: The quality and effectiveness of the support provided to people with disability who show challenging behaviour can be influenced by the design and content of their behaviour support plans (BSPs). This study examined some of the factors that might influence the quality of behaviour support plans and the impact of quality of BSPs on the use of restrictive intervention.

Method: An audit of the quality of a sample of BSPs submitted to the Senior Practitioner in Victoria in the years 2009 and 2010 was conducted using the Behavior Support Plan Quality Evaluation, 2nd Edition (BSP-QE II).

Results: Factors found to positively influence quality of BSPs included: involvement of behaviour consultants and involvement of clinicians from the Office of the Senior Practitioner (Office). Overall quality of plans was also negatively related to restrictive intervention use over time.

Conclusions: The findings support the need for behaviour intervention and provision of clinical support. The findings also provide tentative support for the notion that the inclusion of evidence-based quality components into behaviour support plan formats may reduce the use of restrictive interventions.

The content validity of the behaviour support plan quality evaluation tool (BSP-QEII) and its potential application in accommodation and day-support services for adults with intellectual disability

Background The quality of support provided to people with disability who show challenging behaviour could be influenced by the quality of the behaviour support plans (BSPs) on which staff rely for direction. This study investigated the content validity of the Behaviour Support Plan Quality Evaluation tool (BSP-QEII), originally developed to guide the development of BSPs for children in school settings, and evaluated its application for use in accommodation and day-support services for adults with intellectual disability.

Method A three-round Delphi study involving a purposive sample of experienced behaviour support practitioners (n = 30) was conducted over an 8-week period. The analyses included deductive content analysis and descriptive statistics.

Results The 12 quality domains of the BSP-QEII were affirmed as valid for application in adult accommodation and day-support service settings. Two additional quality domains were suggested, relating to the provision of detailed background on the client and the need for plans to reflect contemporary service philosophy. Furthermore, the results suggest that some issues previously identified in the literature as being important for inclusion in BSPs might not currently be a priority for practitioners. These included: the importance of specifying replacement or alternative behaviours to be taught, descriptions of teaching strategies to be used, reinforcers, and the specification of objective goals against which to evaluate the success of the intervention programme.

Conclusions The BSP-QEII provides a potentially useful framework to guide and evaluate the development of BSPs in services for adults with intellectual disability. Further research is warranted to investigate why practitioners are potentially giving greater attention to some areas of intervention practice than others, even where research has demonstrated these others areas of practice could be important to achieving quality outcomes.

The impact of the quality of behaviour support plans on the use of restraint and seclusion in disability services

Background: Behaviour support plan (BSP) quality is known to be an important aspect of the support provided to people with disability who show challenging behaviours and has been found to lead to reductions in challenging behaviour. Preliminary evidence suggests that quality of plans is associated with reductions in the use of restraint
and seclusion.
Method and materials: Quality of a sample of behaviour support plans was assessed using the Behaviour Support Plan – Quality Evaluation II (BSP-QE II) Guide (Browning Wright, Saren & Mayer, 2003). Episodes of restraint and seclusion before and during implementation of plans were examined by comparing restraint and seclusion use between individuals with high quality versus low quality plans.
Results: Compared to individuals with low quality plans, individuals with high quality plans were found to be subjected to less restraint and seclusion over time, while those with low quality plans were subjected to increases. With the exception of one quality component, all components in high quality plans were found to be associated with decreases in restraint and seclusion use.
Conclusions: The results support earlier preliminary findings that quality of behaviour support plans are associated with reductions in restrictive intervention use. The findings are important because they suggest that increasing quality of behaviour support plans may lead to decreases in restraint and seclusion over time.

Young people with an intellectual disability: risk and resilience.

There is a large body of literature about personal risk and resilience among children and adolescents from a variety of subpopulations. However, in intellectual disability research, resilience has almost exclusively been investigated and reported at the level of family stress and coping rather than an individual child's capacity to function adaptively despite severe risk. In this study young people with an intellectual disability, family members and non-family members (carers, teachers and family friends) were interviewed and asked about the young people’s relationships, coping styles, behaviour patterns and resilience. The main features placing these young people at risk included having autism or inflexible patterns of behaviour, displaying some forms of challenging behaviour, difficulty with receptive and expressive communication, living in families with high competing demands for time and living in a relatively unaccommodating community environment. The main factors leading to resilience were an attractive appearance/disposition, ability to get one’s message across, ability to adapt behaviour to changing contexts, low family stress levels and high sense of competence, stable relationships with supportive others and an accommodating/accepting community environment (both school and social).

Active support, participation and depression

Background
Staff training in Active Support is designed to enable direct support staff to increase the engagement and participation of people with intellectual disabilities in a range of daily activities.

Method
Residents (n = 41) and staff of nine group homes participated. The effectiveness of Active Support was evaluated with a pre-test:post-test design, using a number of standardized assessments and other questionnaires, with group home staff as informants. These assessments were conducted before Active Support training and an average of 6.5 months later.

Results
Following implementation of Active Support residents experienced significant increases in domestic participation and adaptive behaviour. There were significant decreases in internalized challenging behaviour, overall challenging behaviour and depression. There was no significant pre–post change in other forms of challenging behaviour.

Conclusions
Our findings confirm and extend previous Active Support research showing that implementation of Active Support is followed by increased resident participation in activities. The significant improvements in adaptive behaviour, challenging behaviour and depression are of particular interest as the present study is among the first to report such effects. The study’s limitations are discussed.

A preliminary investigation of the utility of the "Behavior support plan quality evaluation guide II" for use in Australia

Background The quality of behaviour support plans (BSPs) can be an important influence on the quality of the support provided to people with disability who show challenging behaviours. The Behavior Support Plan Quality Evaluation Guide II (BSP-QE II) is one tool that may be useful in assessing the quality of behaviour support plans. It has previously been used to assess BSPs to support children in schools in the USA. In this preliminary study, we examined the utility of the BSP-QE II for assessing behaviour support plans designed for adults with an intellectual disability in community support services in Australia.

Method  Experienced practitioners were surveyed concerning the relevance of BSP-QE II components to the evaluation of BSPs in Australia, and an audit was conducted of randomly selected BSPs submitted as a statutory requirement to the Office of the Senior Practitioner.

Results  The BSP-QE II showed evidence of acceptable construct validity and interrater reliability. There was evidence of a need for substantial improvement in the quality of BSPs, consistent with previous findings conducted using other audit tools.

Conclusions The findings support the utility of the BSP-QE II, to inform and evaluate service planning in supporting adults with intellectual disability who show challenging behaviour.