CONFERENCE
Wednesday 26th June 2013
Bristol
Active Support
as a Primary Prevention Strategy for
Challenging Behaviour
Dr Edwin Jones & Professor Kathy Lowe
Service Development Consultants
Directorate of Learning Disability Services
Do you
want to
make a
cup of
tea
1. The Different Levels Of Assistance
ASK- INSTRUCT- PROMPT- SHOW- GUIDE
>>>>>>
level of help increases
>>>>>>>>>>>>>>>
2. Thinking In Steps
Breaking things down into steps & doing one step at a time
3. Reinforcing Participation
Paying attention to service users when they are actively participating and
maximising naturally occurring rewards
2
Active Support (Jones et al. 1999)

Around for over 30 yrs had to be reintroduced in
1999 despite it’s proven effectiveness
 Strong evidence that Active Support (AS) very
effective in improving quality of life of PWLD by
improving staff interaction and planning
 Some indications that those with the highest
support needs benefit most and that interactive
training and practice leadership are key
components

(Felce et al 1986, 2002a, 2000b, Jones et al 1999, 2001b, Mansell
et al 2003, 2008, Stancliffe et al, 2007; 2008; 2010 Toogood 2008,
Totsika et al 2008b Beadle-Brown 2012;)
Positive Behavioural Support (PBS)
A Definition
Values based, person centred technology
Understanding why a person has challenging behaviour
Changing the environment, reducing the need for
challenging behaviour
Respecting and including the person
Improving the skills and quality of life of the person and
those around them
Keeping people safe
Tried and tested
AS & PBS
 Similar
origins in Applied behaviour
Analysis & Social Role Valorisation
 Non aversive- no punishment or
 Primary Prevention= Improving
environment so people get what they need
without having to use Challenging
behaviour
 Key concept- improvements in quality of
life lead to reductions in CB
AS & CB
 Little
focused research on AS & CB
Methodological issues
 Direct Observation (e.g. MTS)--Highlights
high frequency “minor(?)” CB e.g.
stereotypy
 Staff reports –highlights low frequency
high impact ‘major’ CB e.g. aggression &
destruction
 Most AS studies to date have used direct
observation
Direct obs studies
 Jones
et al 2001a
 Smith et al, 2002
 Mansell et al, 2001
 Bradshaw et al, 2004
Research on AS and CB
 Stancliffe
et al, 2007; 2010
 Koritsas et al, 2008
 Beadle-Brown et al, 2012
 Toogood et al, 2009, 2011
Current research
3
studies
 (direct

observation)
Study 1 – secondary analysis
 Systematic


clinical data
Study 2 – resettlement from hospital
Study 3 – redevelopment of existing service
Study 1
5
well established supported living houses
 Total of 19 participants
 Selected to represent people with
profound to severe learning disabilities
 Only house 1 had no participants with CB
House 1
100
%
80
60
40
20
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
tim e points
c hallenging
behav
House
3 iour
engagement
%
70
60
50
40
30
20
10
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
19
20
21
22
21
22
21
22
t im e point s
c hallenging behav iour
Hous e 2
engagement
80
70
%
60
50
40
30
20
10
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
t im e point s
c hallenging
behav iour
House
engagement
4
100
%
80
60
40
20
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
t im e point s
c hallenging
behav iour
%
Hous e
engagement
5
80
70
60
50
40
30
20
10
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
t im e point s
c hallenging
behav iour
engagement
19
20
STUDY 2






Resettlement in North Wales
Active Support introduced
Functional analysis (NHS staff)
Behaviour management plans (secondary and
reactive)
Data from systematic clinical records (incidents,
participation, community use, as required meds)
4 service users – very serious behaviours
Service user B
Service User A
800
Number
Number
600
400
200
0
1
3
5
7
9
400
350
300
250
200
150
100
50
0
11 13 15 17 19 21 23 25 27 29 31
1
3
5
7
9 11 13 15 17 19 21 23 25 27 29 31 33 35
timepoints
CB incidents
timepoints
Participation
CB incidents
Service User D
600
600
500
500
400
400
number
number
Service User C
Participation
300
200
100
300
200
100
0
0
1
3
5
7
9
11
13
15
17
timepoints
CB incidents
19
21
23
1
3
5
7
9
11
13
15
17
19
timepoints
Participation
CB incidents
Participation
21
23
25
Study 3







Major redevelopment (NAS) – 4 years
19 service users
New operational procedures
Active Support, Studio 3
Baseline – 2005, Post data – 2010
Measures – ABS, ABC, incidents, community
use
4 service users – high levels of cb at outset
Service User 1
Number of Incidents
number of incidents
35
Service User 2
30
25
20
15
10
5
80
70
60
50
40
30
20
10
0
1
2
3
years
Years
Service User 3
Service User 4
40
35
30
25
10
number of incidents
number of incidents
0
20
15
10
5
0
8
6
4
2
0
years
years
4
Summary of results
 Different
methodologies highlight different
behaviours


Observation – stereotypies
Incident recording – other behaviours
conclusion – AS led to reduced CB
and increased engagement in activity
 Similar
 CB
not eliminated - caution
AS as Primary Prevention
Behaviour
Function
Unhelpful
environment
Provide Helpful environments
Get away
(Escape or
Avoidance)
Aversive situations
e.g. Complex
demands
Remove, reduce & manage
aversives e.g. Provide more
support and assistance
Increase social
contact
(attention)
Low levels of social High levels of social contact,
contact mainly
mainly contingent on adaptive
contingent on CB
behaviour
Adjust sensory
stimulation
(sensory)
Under or over
stimulating
environments
Typical places with meaningful
activities or calmer places still
with typical things to do
Get something
(tangible)
Limited access to
preferred
objects/activities
Materials and activities which
are readily and predictably
available
Other Factors include
 Severity
of learning disability
 Inactivity
 Lack of structure/predictability of activity
 Mental health issues
 Poor health
AS helps achieve least
restrictive environments
Padlocks on fridges are a very stark image of
a restrictive practice and a custodial prison
like environment
Restrictive practices, are unethical, aversive
and can act as setting conditions or triggers
for challenging behaviour (service user D)
Active Support provided the technology to
remove the locks from the fridge enabling safe
unrestricted access to food his desired
tangible removing the main trigger for CB
Active Support can act as a powerful cultural
change agent—changing staff attitude by
proving alternative practice can work
A Vicious Circle In Hotel Models
Staff do most things for
service users, they react to
CB by using restraint /
seclusion/ sedation
Staff think reactively
& use punishment to
control CB. ‘domestic
worker / security
guard’- Role-Keep the
house clean and no one
gets hurt too badly’
Service users use
CB to control the
environment—they
do not participate
and spend most
time doing nothing
Staff perceive service users
as dangerous, dependent &
unable, they do not interact
with or assist service users
Primary
prevention
Changing
person’s physical environment
Altering programmatic environment
Introducing total communication
Addressing internal setting events (mental & physical health)
Improving carer confidence & competence
Eliminating or modifying specific triggers for behaviour
Increasing rates of access to preferred reinforcers
Increasing the density of social contact
Increasing rates of engagement
Modifying demands
Providing additional help
Embedding
Building behavioural momentum
Teaching general skills
Teaching functionally equivalent skills
Teaching coping skills
Secondary
prevention
Stimulus
change
Stimulus removal
Coping skills
Not ignoring
Strategic capitulation
Diversion to reinforcing activities
Diversion to compelling activities
Reactive
strategies
Proxemics
Self-protective
Minimal
‘Ethical’ Restraint
Helpful Environments: Virtuous Circle
Staff provide opportunities and
assistance for service users to
participate. This helps to prevent
CB. If CB does occur they respond
positively-rather than punish
Staff think
proactively and
creatively –
improving
interaction and
communication.
Staff see
themselves as
enablers
Service users
participate
successfully in
some activities.
Q of L improves
CB decreases
Staff perceive service users as less
dangerous & more competent. Staff
give service users more respect,
control & attention. Staff feel more
confident, successful & eager to try
new things
Full reference:-
Jones, E., Lowe, K., Brown, S., Albert, A., Saunders, C.,
Haake, N & Leigh, H. (2013). Active Support as a primary
prevention strategy for challenging behaviour. International
Journal of Positive Behavioural Support, 3 (1), 16-30.
Diolch
Edwin.Jones@wales.nhs.uk
Kathy.lowe@wales.nhs.uk Thank You