INTRODUCTION
•Over a third of individuals with Intellectual Disability under
care of local authorities reside in out of borough placements
(Whelton, 2009, see: McGill et al, 2010).
•Prominent in this group are individuals who exhibit behaviour
that presents a challenge to services (Emerson & Robertson,
2008, see: McGill et al, 2010).
•Out of borough placements are often high cost and of
dubious quality.
•Such placements often occur as a reaction to crisis situation.
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Case Study: Anna
• Anna is an adult with a learning disability
• Anna was placed in an out of borough residence, due to
a lack of local expertise in supporting people whose
behaviour challenges
• The out of borough placement was of dubious quality,
yet very costly
• Anna lived in an isolated environment, detached from
typical community living
• Some evidence of restrictive practices was observed in
the setting
• Opportunities for engagement in leisure, domestic and
social activities were extremely limited
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Case Study: Anna
• Anna was unoccupied for long periods of time
• She engaged in regular, high levels of undesirable
behaviours, including:
– Aggression towards staff
– Undressing in inappropriate situations
– Urinating inappropriately
• No consistent behaviour interventions were being used
• Anna was prescribed with significant amounts of
medication, in an attempt to control her behaviour
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Anna’s Previous Home and
Surrounding Area:
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The Mansell Report:
• The Mansell Report (Revised edition: 2007)
recommends specialist challenging behaviour services
(a) work intensively with a small number of individuals
and (b) help strengthen mainstream services so they
can serve people locally.
• Research on specialist Challenging Behaviour services
suggests effective services are likely to be:
(a)Peripatetic
(b)Psychology-led,
(c)Have good case management procedures
(d)Clearly orientated to evidence-based approaches in
behaviour analysis (Forrest et al. 1996).
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Halton Borough Council:
•Halton Borough Council alongside Halton CCG have
commissioned a specialist peripatetic challenging behaviour
support service.
•Neighbouring authorities Knowsley and St Helens
Council/St Helens CCG are also commissioning the
service.
•The Positive Behaviour Support Service (PBSS) is an
invest to save service.
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Positive Behaviour Support Service (PBSS):
•The PBSS is a cross-borough, Local Authority led, lifespan
(adult’s and children’s) service.
•It is the first in the UK to be staffed and led by Board Certified
Behaviour Analysts (BCBA)
•The Behaviour Analysis Certification Board (BACB ®) certifies
and regulates behaviour analysts. Over the last ten years there
has been a steadily increasing demand across Europe for
Board Certified Behaviour Analysts (BCBA: Hughes & Shook,
2007).
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BCBA status:
• BCBA certificate holders have at least an MSc in Applied
Behaviour Analysis from a BACB approved course.
• 1500 hours minimum supervised work experience, with at
least 75 hours of contact supervision from a BCBA is also
required.
• Ongoing clinical and professional development is required
to maintain the BCBA qualification.
• This is done by obtaining Continuing Education Units.
• BCBA holders are required to abide by stringent
professional and ethical guidelines.
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Functional Assessment:
• Behaviour Analysts conduct Functional Assessments.
• Functional assessment is the gathering of specific
information to help understand a challenging behaviour.
• A full functional assessment covers several categories of
information.
• For example: Problem behaviour, antecedent and
consequence events, alternative behaviours, motivational
aspects and reinforcer potential and previous
interventions.
• A Functional Assessment can be indirect (interviews,
rating scales etc); direct (observations etc) and
experimental (purposeful manipulation of environmental
variables).
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Core Aims of the PBSS:
For the individual service users…
• Improved quality of life
• Increased opportunity for meaningful engagement
• More opportunity for education/cognitive development
• Increased opportunity for community participation
• Greater access to a less restrictive environment
• Improved relationships
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Core Aims of the PBSS:
For those caring for or supporting individual service
users…
• Reduced stress
• An increased knowledge and understanding of behaviour
function, environmental and stimulation effects
• An increased efficiency during times of problem
behaviour occurrence
• Improved relationships with service user
• An increased confidence in ability to cope
• A feeling of being supported.
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Core Aims of the PBSS:
Overall risk reduction…
• Damage to health and social well being
• Personal injury
• Placement breakdown
• Out of borough/restricted placement
• Reaching crisis point
• Damaged relations
• Preceded by one’s case history
• Intrusive support levels
• Normal life opportunity limited by over zealous risk
assessment
• High cost placement/support packages
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Service Aims:
The service will work collaboratively in four related areas:
•Early Intervention
•Crisis Prevention and Management
•Technical support
•Placement Development.
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Early Intervention:
•The PBSS will provide an Early Intervention service to
high risk groups e.g. children with Autistic Spectrum
Conditions.
•Early intervention work will consist of:
•Parent/Carer training workshops
•Work with individuals
•Close working with schools
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Crisis Prevention and Management:
•The PBSS will have a prominent focus on crisis
prevention and management. Such work will include:
•Developing mainstream service staff competencies and
mentoring
•Mechanisms for surveillance i.e. behaviour monitoring,
early identification of potential behaviours that may
present challenges to services.
•Prevention of placement breakdown and out of borough
placement
•Eligibility criteria for crisis situations
•Single and multiple consultations
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Crisis Prevention and Management:
• The PBSS will also aim to have presence at key risk
times
For example:
• Transition from children to adult services
• Staff change over
• Placement change e.g. changing schools, transition in to
a new placement such as day services.
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Technical Support
The PBSS will provide specialist individualised treatment for
the most complex cases. This will include:
•Referral, review, and allocation for full functional Assessment
•Person centred intervention plan
•Clear service exit preparation
•Follow up and maintenance (Linking back into crisis
prevention and management)
Placement Development
A core aim of the PBSS will be to return people who are
currently out-of-borough to their local area.
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Potential Challenges:
• Resistance
• Referral pathway complications
• Competing priorities
• Professional rivalries
• Immediate financial pressures (invest to save)
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TRAINING:
The PBSS aims to provide effective training for parents/carers and staff supporting
individuals e.g. supported housing staff/teachers/day service staff.
ACTIVE SUPPORT
Engagement
•
Engagement is defined as (a) participating in a constructive activity e.g. laying
the table, and (b) social interaction e.g. having a conversation and participating
in group activities (Mansell et al, 2005).
•
Engagement like this provides increased opportunity to develop relationships,
opportunity to a more varied life experience and also give better prospects for
making informed choices.
•
Researchers working with people with intellectual disabilities, identified two
variables that influence engagement in everyday meaningful activities
(Ashman, Ockenden, Beadle Brown & Mansell, 2010).
1) The skill level of the individual
2) The level and quality of support given to that individual by staff
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ACTIVE SUPPORT (Cont’d)
Engagement (Cont’d)
An overall aim of active support is for staff to provide the correct level of support to
individuals, so that they can engage in meaningful everyday activities (Jones et al,
2009).
EVIDENCE:
There is compelling evidence for benefits to individuals of implementing active
support (Stancliffe et al, 2008; Totskia et al., 2008).
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Aims of the PBSS for Anna
To improve Anna’s overall quality of life by:
– Enriching her living environment
– Increasing her opportunities for: social interaction;
leisure activities; participation in “normal” activities
and personal development
– Removing the restrictions placed on her physical
environment
– Reducing the occurrence and intensity of behaviours
– Giving her alternative means of communicating her
needs and expressing choice
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Aims of the PBSS for Anna
To improve the quality of support for Anna by:
– Installing consistent intervention plans for behaviour
reduction and skill development
– Training staff in effective support strategies
– Providing continuing advice and support for staff
– Ongoing monitoring through data collection and
analysis
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PBSS Input
The PBSS’ input to date has included:
Assessment and Intervention
–
–
–
–
–
Functional assessment of the target behaviours
Completion of rating scales
Direct observation of Anna’s behaviours
Detailed Person Centred Intervention Plan
Contributing to transition plan for move back to Halton
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PBSS Input
The PBSS’ input to date has included:
Training and Monitoring
– Theory training for new staff team on the principles of
Behaviour Analysis and Active Support
– “On the job” training for each staff member, tailored
specifically to individual training needs
– Team report outlining training targets
– Training in data taking
– Ongoing analysis of data for informed decision
making
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Anna’s Life Now
What has changed?
• In January 2011, Anna returned to live in Halton
• She now resides in a bungalow in a typical residential
road
• Anna has unrestricted access to all areas of her home
• Staffing levels have reduced at certain times of the day
• Staff actively plan activities across the day
• Staff encourage participation in “normal activities”
• Staff use less restrictive, more effective interventions
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Anna’s Life Now
What has changed?
• Anna is more settled in her new home
• Anna participates daily in:
– Domestic activities
– Leisure and social activities
– Community activities
• Undesirable behaviours have reduced in frequency and
intensity
• Anna’s staff team are confident in how to enrich her
environment and effectively support her
• Improved quality of life…package cost annual saving of
£92, 500
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Cost Effectiveness:
Current/Previous Cost
Saving
-PCT
£ 244,400/year
£140,000
-HBC
£175,000/year
£30,000
-HBC
£ 210,000
£45,000
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Anna’s Current Home and
Surrounding Areas:
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CONTACT DETAILS:
Maria Saville BCBA- Principal Manager Positive Behaviour Support Service
Maria.Saville@halton.gov.uk
Dr Sandy Toogood BCBA-D- Consultant Behaviour Analyst
s.toogood@bangor.ac.uk
Paul McWade- Operational Director Complex Care, Halton Borough Council
Paul.McWade@halton.gov.uk
Kath Devonshire BCBA- Practice Manager Positive Behaviour Support Service
Kath.Devonshire@halton.gov.uk
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