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’
‘Staff were happy as she allowed them to interact with her…even for the staff she targets.’
‘I felt happy seeing her calm and change in her behaviour’
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.
Positive Support Coordinator