Intensive Interaction and Challenging Behaviour – A case study

The following is a case study of a female client, SA, who has diagnosis of severe learning disabilities, autism and associated communication difficulties. SA is non-verbal and communicates through objects of reference, body language and challenging behaviour, in form of self injury behaviour or aggression to others. Some of the challenging behaviours include banging her head, biting and scratching areas of her body, hitting, biting and hair pulling and or head butting others.   A pattern emerged over time where the reduction in one form of self injury behaviour was often replaced by other high risk behaviours (e.g. acrobatics).  SA experiences periods of extremely distressed and unsettled behaviour- defined as amber and red arousal states. These periods last from few hours to couple of days, followed by period of time when SA is settled.

At times over the last twelve years these periods would sustain for up to several months, with little respite from her distress.  Numerous investigations into possible underlying health issues were undertaken but no problems were ever identified which would explain the situation.  The close supervision often needed to support SA in all her activities e.g. personal care, eating and drinking, and bathing after frequent smearing behaviour meant that she experienced regular demands throughout the day, that resulted in challenging behaviour that subsequently reduced the opportunities for positive staff interactions.

Despite these challenging episodes, SA is still very sociable, and one of her strengths is her ability to develop close and lasting relationships with co-workers.  Close contact with and support from co-workers is extremely important to SA but during extended periods of challenging behaviour these relationships came under severe stress.  Despite these challenges, the whole team of co-workers would persevere in working with her, and try to work out why SA was feeling so distressed.

In June 2015, SA presentation suddenly deteriorated, where she exhibited high level of self injury behaviour (biting self and banging head on hard surfaces) and aggression directed to others. Due to high frequency and severity of presented behaviours she was referred to Learning Disability Team and Intensive Support Team. Both teams, carried extensive work (functional assessment of challenging behaviour including observation, staff systematic sessions, communication assessment and medical investigations, including dental treatment, blood test undertaken under general anaesthetic) to find causes of sudden onset of the self injury behaviour. No new information about the causes or functions of SA’s stressed behaviours was identified during this process, although it was already understood that her stress was linked to communication needs, attention and interaction.

New strategies were implemented by the positive support co-ordinator and teams at the home to reduce level of SA’s anxiety such as: small circle of support (only few co-workers were supporting SA), changes in the environment (she moved from main building, which she shared with 5 other service users, to annex in the garden).  In addition medical interventions (Olanzapine) were applied. New strategies reduced SA self injury behaviour but aggression directed to others remains on the same level.

The change of living area for SA was accompanied by a reduction in the SIB as she was able to spend time away from noisy and unpredictable environments, but her stress remained high whenever she saw non-preferred co-workers.

During this period, work was also done by the teams to identify the key characteristics of the co-workers that SA would accept, which included a calm, quiet demeanour and an ability to support SA at her own pace and without a perception of demands.  Being highly responsive and supporting SA to take the lead proved a successful approach when carried out by this small team, and challenging behaviours gradually reduced.

Small circle of co-workers, who worked with SA over last 18 months. From left: Alex, Emma, Katy, Zoe, Lorraine (behind), Diana, Maria and Emma B (not at the picture)

In May 2016, co-workers received extensive Intensive Interaction training from Mr Jules McKim from Southern Health NHS Foundation Trust.  The aim of training was to encourage staff to interact at an appropriate developmental level for SA, and to demonstrate to SA that interactions are not all demands based, and provide her with opportunities to learn fundamental communication skills and enjoy her time with others.

After the intensive interaction training, there were three scheduled follow-up meeting with Mr McKim, where co-workers was able to reflect and discuss what was working. Intensive Interaction session recording forms and videos of SA and co-workers were available for review and discussion, where different intensive interactions techniques were discussed. During second meeting in December 2016, co-workers reported that interactions with SA were ‘amazing’ and SA is more seeking out face to face contact and interactions. At this time SA was still supported by a small core team of female co-workers with whom she had close and trusting relationships, but would also by now seek out and accept support from less preferred co-workers in the wider teams. The last follow-up meeting took place in February 2017, where co-workers again shared their experiences and how they felt about intensive interactions. Here are few quotes from the session and Intensive interaction session recording forms:

‘I am happy that I and SA had a good session… that SA led the session.’

‘Really happy and proud that SA was laughing and looked so relaxed’

Katy

‘Staff were happy as she allowed them to interact with her…even for the staff she targets.’

Maria

‘I felt happy seeing her calm and change in her behaviour’

Lorraine

Since co-workers have been using the Intensive Interactions approach, SA learned that interactions did not have to be based on demands and she gained control over interactions and to a lesser extent, the environment. Currently she presents herself in calm and settled mood with occasional days where is more anxious, but level of challenging behaviour directed at others is much less frequent and severe.

Figure 1, shows SA’s arousal level from June 2015 to April 2017. Amber arousal level- unsettled, anxious not able participate in offered activities, red arousal level- distressed, highly anxious.

Katarzyna Kowalska

Positive Support Coordinator

Doing what we do

At Liaise we are proud of our reputation as a specialist service so we were very pleased to receive the following email recently praising our coworkers for their professionalism and positive attitudes.

This was from a former teacher of a new service user who has recently moved into one of our services (published with her permission).

Hi

I’d just like to share my thoughts and feelings on a current transition of one of my pupils to Marika House.

marika-house-newI’ve been A’s teacher for 3 years having come from mainstream to suddenly be teaching a highly challenging class at Tadley Court School with A as one of the most challenging pupils in the school. I immediately developed a very close working relationship with A regardless of the daily behaviours he demonstrated. He has come a long way. So much so he is now (mostly) to be able to self manage his anxieties.

For the past 3 years I’ve been anxious about A’s transition into post 19 provision.  I needn’t have been. The transition plan that was put in place by Marika, rather than ourselves, has been second to none. Each and every staff that has met A, or myself, have told me how excited they are to get to know him. This has given me even more confidence that this is the best place for A.

I have every confidence that Marika house is the best place for this special young man. I’d like to pay a particular thank you and commendation to Lizzie who has ensured a flawless transition as well as developing an immediate positive  relationship with my special boy!

Many many thanks

Claire

The new homes at Oakley are currently being modernised and updated to the high level standards that we expect in all of our homes

5 Kennet5 Kennet rear

They are smaller than normal homes and are bungalows ideal for one or two people depending on needs.

We were told about them by Dave and Andy, our usual builders, and one of the attractions was that they are adjacent to each other and it is rare that the opportunity to purchase two properties like this arises.

The other attraction was that one was empty and the other had a tenant whose lease was ending and so this made the purchasing process easier – although it never seems to be as smooth as you think it should be.

Almost inevitably though any new property requires some alteration and refurbishment to bring it up to the standard to give the right environment for the people who will be living there. Windows often do not meet the required safety standard and the kitchen, flooring, heating and electrics need improving. For these properties we are replacing windows and doors, kitchens and boilers.

In one, we are installing a second bathroom which meant altering drainage to suit. Both will also have nearly all new flooring too. The windows will have integral blinds to give better privacy and remove the need for curtains.

We need to make the properties safe and installing fire doors and smoke detectors even though the properties will be staffed 24 hours per day.

We are also making improvements to the boundary fencing to improve security, so that the individuals living there can safely use the garden unaccompanied, and give some additional privacy. Initially there will be a low fence between the two rear gardens but in time we hope to be able to remove this to open the space up and provide a good area for everyone to get outside and share the space.

Both properties have garages and one is being converted to an office and the other a laundry room. There is on-site parking for both properties and with adequate other parking facilities nearby if required.

Fortunately we have already secured agreement for two new people to come to and live in these properties and hope to secure a third soon which would mean we will have filled the available places ahead of them being ready.

One person is going to have one of the bungalows to themselves so that they can have the space that they need to have a great live with us at Liaise. We are already starting the transition process for one of their new neighbours.

These new properties are being managed by Andy Key, who currently manages Baytrees, and recruitment is underway to have staff in place for when new people move in.

We are in the process of purchasing another property near Southampton and there will be more on that in the future.

Towards Independence – Learning through ASDAN

Circle of SupportEach individual has a Circle of Support which co-ordinates the assessment, planning, implementation and regular review of the support plan including the person’s flexible daily activity schedule.

The activities are selected to reflect what each individual is motivated by and enjoys doing and also to promote ongoing learning and the development of life skills.

As well as promoting greater engagement and independence these skills are also an important part of reducing behaviours of concern that can restrict the person’s opportunities.

The individual’s learning, where appropriate, can be delivered and celebrated through the use of the ASDAN Towards Independence Learning modules.

We are a recognised organisation to deliver both AQA Unit Award Scheme and ASDAN Towards Independence Programme.

Linzi Holt, one of our senior specialism leaders, is the recognised scheme co-ordinator for both. As a member we must comply with their procedures.

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Towards Independence

What is it?

“Towards Independence” provides a framework of activities through which personal, social and independence skills can be developed and accredited for those with severe learning difficulties (SLD) and profound multiple learning difficulties (PMLD).

Who is is for?

Post-16 learners

“Towards Independence” can be undertaken at colleges, residential homes, schools, day and care centres and across local authority and private provision.

Structure

Towards Independence offers formal recognition for small steps in achievement towards a larger goal.

Modules can be used separately and accumulated to build a record of personal achievements.

There are almost 50 different modules to choose from, and the first of these – Starting Out – is mandatory.  Working through Starting Out allows learners to be helped to recognise achievements and plan targets and challenges, which can then be developed through further modules.

Learning at Liaise – Over recent months learners at Liaise have been working on modules such as Making Pictures, Getting Ready to Go Out, Meal Preparation and Cooking, and Multi-Sensory Experiences

Starting Out works well at Liaise as it is a good practical Assessment and planning tool, and works well alongside other assessments such as the IABA La Vigna & Willis Behaviour Assessment Guide (BAG)or Liaise’s information gathering tool for person centred planning, “What’s Important To ….”

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Marika 3! A New Single Person Unit

It might not be the most exciting name at the moment, but it is going to be a life changing project for one of the people we support.

In our continual drive towards increasing personalisation, we are building a one person, self contained unit in the grounds of Marika House.

This been designed specifically for one of the people who live in the main house. They have been having increasing problems sharing the main house with other people, but really wanted to stay.

So, after a lot of conversations with everyone, getting planning permission and finally, approval by building control, work has started!

It will be a little bit of madness around the home for the next 20 weeks. We will be minimising the effects for all and hoping for a dry summer.

So, the trucks and diggers are moving on to the site…

P1050429     P1050430

 

And the hole for the foundations has started to be dug…

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And a fence to keep everyone safe.

Follow us on facebook to keep up with the developments over the next few months.

 

What is Autism?

Autism ……

  • is a lifelong condition that affects how a person communicates with and relates to other people
  • means differences and difficulties in three main areas known as the “Triad of Impairment”:
    • social communication: problems using and understanding verbal & body language
    • social interaction: problems in recognising and understanding other people’s feelings, and in managing their own
    • social imagination: problems understanding & predicting other people’s behaviour and intentions and imagining situations outside their own

Autism ……

  • affects the person’s senses, and how they experience the world around them
  • can mean that the person may experience some form of sensory sensitivity or under-sensitivity, for example to sounds, touch, tastes, smells, light or colours. Sensory issues can mean the person also has difficulty with body awareness, may have problems moving around easily or hold their bodies in unusual positions
  • can mean the person prefers a fixed routine and finds change incredibly difficult
  • can mean the person needs lots of support to cope with a world that is unpredictable, confusing and frightening
  • may affect the way a person conducts themselves, using behaviours that can be rigid, unusual and/or challenging to those around them

Autism ……

  • is an umbrella term that covers autistic spectrum disorder (ASD), autism spectrum condition (ASC), autistic spectrum difference, neuro-diversity & Asperger’s syndrome
  • is a spectrum disorder, affecting individuals in different ways and with varying severity. For example, people who have Asperger’s syndrome typically have fewer problems speaking than others on the autism spectrum, but still have significant problems with communication that can be masked by their ability to speak fluently. They are often of average or above average intelligence
  • can occur in combination with other conditions such as learning disabilities, ADHD (attention deficit hyperactivity disorder) or specific learning difficulties such as dyspraxia

Ref: “Fulfilling and rewarding lives: Implementing the Autism strategy for adults” Department of Health 2010

Liaise Loddon Ltd ……

  • is an independent organisation with many years experience providing personalised services for adults most profoundly affected by autism and severe learning disabilities, and who are at risk of being excluded from many activities, experiences & services in our communities
  • uses positive approaches to support individuals to build on their strengths and overcome barriers to living a life of their choosing
  • ensure relationships are built and nurtured with the individual, the whole family, staff, advocates and placing authorities to ensure the highest standard of service is provided at all times.

From Old Garage To Self-Contained Unit

When a new person comes to Liaise to live with us, we work really hard to create a space tailored specifically to their needs. Somewhere just for the individual; somewhere personal.

This isn’t always the easiest project, because we have to work within existing buildings and rooms.

So we were delighted when we got planning permission to convert the old double garage at Marika House into a brand-new single-person unit.

We started work straight away, and we’re hoping to have it completed within a few months.

Here’s what it looked like before:

The interior of the old garage, looking at the double doors The exterior back of the old double garage The front of the old double garage at Marika HouseSome old junk inside the double garage before work started

Things are moving on pretty quickly, though – take a a look at the work so far:

Scaffolding on the old double garage The old double garage is reduced to a shell with no roof

We’ll keep you updated on the blog – and let you know how the new person gets on!

A Big Adventure For Willow Tree And Baytrees

Willow Tree Lodge and Baytrees House had an exciting day out on July 14 – they went off to the Queen Elizabeth II Activity Centre for the day.

It was a gloriously hot, sunny day down near Southampton – so there was a lot of suntan lotion, and the local pub beer garden did a roaring trade at lunchtime.

The people we support had great fun exploring a whole lot of activities – but archery was probably their favourite. H won the golden arrow with a whopping 120 points…

But L gave her a run for her money and scored a bullseye with one shot.

The motorboat proved to be a big hit too, with P and H both discovering a hidden talent at motorboat piloting.

P impressed us all on the climbing wall when he made it all the way to the top and rang the bell.

But the coolest dude of the day must have been G – who bypassed most of the rope course in favour of chilling out on a particularly comfy-looking tyre.

Everyone had a fab time – but trips like this are about more than just having fun.

A big part of what we do is making sure the people we support – people with severe autism – can play a fulfilling and meaningful role in their communities, and in society in general. This type of activity gives them the chance to do the stuff that we all take for granted.

They learn new life skills, absorb new experiences, and strengthen relationships.

Deprivation of Liberty Safeguards and the Mental Capacity Act

If you’ve been following the news, you’ll have heard about the recent House of Lords Ruling about DOLS (Deprivation of Liberty Safeguards) and the Mental Capacity Act 2005 (MCA). You can read more about the committee, report and recommendations here.

The House of Lords appointed a select committee in 2013 and received the report in February 2014. The committee recommended that the Government should scrap DOLS and replace it with a new framework that better protects the rights of vulnerable adults in care settings.

The committee found the current DOLS operation was leading to thousands of people who were unable to consent to care arrangements being unlawfully deprived of their liberty. The safeguards are supposed to protect individuals against this kind of deprivation – but were failing to do so.

‘Poorly drafted and poorly implemented’

“The provisions are poorly drafted, overly complex and bear no relationship to the language and ethos of the Mental Capacity Act,” said the committee’s report. “The safeguards are not well understood and are poorly implemented. Evidence suggested that thousands, if not tens of thousands, of individuals are being deprived of their liberty without the protection of the law, and therefore without the safeguards which Parliament intended.”

Since the report was published, there has been a huge increase in court applications and many residential care homes are getting visitos form DOLS assessors to find out if people’s liberty is being restricted in any way.

At Liaise, we’ve obviously been following this closely and Glebelands had its own visit from a DOLS assessor in June.

We are proud to report that the assessor said he was very impressed by the level of behaviour analysis and support we deliver and would let the relevant authority know that.

At Liaise, we provide the least restrictive environment possible while keeping the people we support safe, so we were delighted to see this ‘balancing act’ recognised and praised because our staff work very hard to achieve it.

How we achieve our ‘balancing act’

This seems like a good place to tell you a little about how we achieve our ‘balancing act’. We run specialist worker training bi-monthly/eight-weekly. This is ongoing training to ensure our colleagues continue to develop themselves and the people we support.

This month, we continued to focus on service-user learning objectives. These are the short-term goals the people we support work on to develop life skills and coping strategies.

These objectives help to bring the person closer to achieving a lifestyle of their choosing and reaching their long-term aims. Learning new skills and building on existing strengths is a key part of reducing challenging behaviours and improving life experiences. The skills they learn and develop help to ensure they live their lives as freely – and as safely – as possible.

Progress at Head Office

At our head office, the specialist workers each gave a presentation analysing the many elements they must consider in ensuring the people they support have the best chance of learning. This means assessing, planning, implementing, monitoring, reviewing and measuring progress.

Our colleagues demonstrated that most progress is made when service-users and support staff are all involved in deciding what to work on. The people we support do best when there is lots of discussion to review how things are going.

This is a vital part of our work to ensure the people we support live lives that are as fulfilling, rich, safe and free as possible.

Research Autism: Beyond The Sacred Classroom

Marion CornickMarion, our managing director and founder, is speaking at a Research Autism conference in London on July 1.

This is a real privilege for Marion and for Liaise Loddon. Research Autism asked Marion to speak for them because of her brilliant early career working with children – which has led to her amazing work with Liaise Loddon and the Loddon School.

Marion worked to create curriculums that enable children with autism to develop crucial life skills as they become young adults.

An audience of parents and autism professionals will listen to Marion talk. Her presentation, Beyond the Sacred Classroom, will cover her pioneering work with the Loddon School and her much-needed move into working with young adults with autism at Liaise Loddon.

The Loddon School’s curriculum focuses on learning outside the classroom in a natural setting, where children can practise their skills in real life. We’ve found that children who resist learning in the traditional classroom discover that learning can be rewarding and fun – not threatening.

Most of the children at the Loddon School have struggled with the very idea of a classroom, or have spent most of their time outside it, because of their disruptive behaviour. Marion’s approach is to find a way to help children learn that suits them. After all, their disruptive behaviour isn’t down to them being ‘naughty’, it’s their way of showing they can’t cope with traditional learning. The Liaise Loddon and Loddon School way is a huge positive step for children and young adults with autism towards real learning for life.

You’ll be able to read more about Marion’s presentation next month.