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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

Celebrating the positive

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……………that’s exactly what we have been doing recently.

 

 

The support teams within the Liaise homes have been “Focusing on the positive in those we support”. The use of the ASDAN Towards Independence Programme has enabled the homes to “Create a positive learning culture” in which everyone is aware of “clear, shared goals” with regard to individual’s interests and consequent learning opportunities. The consistent, regular practice of these clear, shared goals over the last year has resulted in a number of individuals achieving their ASDAN Awards in their areas of special interest – namely cooking, art and sensory activities.

Recently, Andrea Ede, Learning and Development Manager, and Linzi Holt, ASDAN Co-ordinator, joined these learners in Applelea, Cornview, Sansa House and Baytrees and presented them with their ASDAN certificates – some rather lovely cakes were also shared!

  Cornview     Applelea     Baytrees     Sansa

There was a joint celebration. This learning would not take place without the consistency of learning support from the support teams in the homes. To show Liaises’ appreciation of the commitment co-workers have put into getting ASDAN running in their homes, co-worker teams also received certificates.

Times change…………..

Liaise Loddon is about to be twenty years old and Loddon School is now about 27 years old but my life in the world of autism and education goes back much further! So a potted history of the changes in education and care.

chalkMy teaching career started 55 years ago when autism had only been identified for 20 years. My first job as a teacher was in a secondary school in Southampton where I taught English – and was amazed to find children there who couldn’t read or write – or some even who did not speak. Did they have autism I wondered? Today they would be in a special school but this was before the 1970 Education Act which gave education for all and so began the idea of special schools rather than training centres and hospitals.

My next job was in a special unit for children who found attending school difficult for various reasons. Here I met some highly intelligent children who had areas of brilliance and were gifted in certain subjects and who would now be seen as ‘savants’ who excelled in maths, music and art. One very challenging young man left this unit and founded a world famous computer company and was a millionaire at 18! Perhaps these were gifted children with autism at the other end of the spectrum from those I met in my first job.

At this time most children and adults with learning disabilities were usually put into the care of a local long stay hospital for the ‘severely sub-normal’. In the USA there were hospitals for such patients where 10000 or more people lived!

Girl drawing back to school

After a year teaching in a hospital school in New Zealand I knew more about autism. You learn quickly when you have a class of 12 children with no classroom assistant help and the children aged from 12 to 21 are your responsibility from 8.30 till 3.30 without a break – unless the teacher who shared the room with you and her 12 children gave you ten minutes to eat your lunch.  It was an exciting year where I learnt a great deal about classroom management and how to work with a wide range of disabilities and challenges.

‘Dibs in search of self’ by Virginia Axline influenced me at this stage – a really useful book!Dibs

On my return to the UK in 1975 I became Deputy Head of Hope Lodge School for children with Autism – a newly established school and one of the first in the UK for children with autism. On my first day one boy jumped out of the window and ran all the way to the shops about a mile away with me in hot pursuit! One child had to go into a long stay hospital for Christmas and I had to take her there. She was number 37 in a ward with one nurse sitting in a glass box office and 36 other children lying on a rather unsavoury carpet with a TV high on the wall but no other toys at all. It was rather like the films of Romania! But made me decide that one day, I would ensure it could be done better.

exam-time

During the 1980s I became Head teacher at Greenacres SLD School in Winchester where I introduced EDDY, real learning and the teaching of reading and a school day with a curriculum, teaching strategies and even their first BBC computer. Then I became Director of Education at Ravenswood Village in Berkshire where there were 200 children and adults living in a special village. In this job I introduced assessment and programmed reviews so that children and adults had targets and opportunities to learn new skills.

So from the early days of teaching in Southampton to the work in Berkshire I was working towards a new way of working with people with disabilities and making sure that each person was given respect and opportunity. It was at Ravenswood that I was introduced by a visitor to the developing programme in New York called SCIP. I worked with Janet Bromley and Linzi Holt to develop the programme and deliver it in Ravenswood so that it became a proactive positive programme forming the basis of our work today in Loddon School and Liaise Loddon now known as PROACT-SCIPr-UK®
Now we have more than 700 instructors teaching positive programming and behaviour supports throughout the UK and even in Zambia where we have 6 keen instructors already.

So my teaching journey began when I as a small girl decided to become a teacher and to ensure that children with disabilities were given real opportunities – and look where we are now! Do you have a vision? Where do you want to be and what do you want to achieve?

The world of disability has changed in my life time and will continue to change so that everyone has an opportunity and no one lives in the conditions I saw in old hospitals, and in Romania. Follow your vision!

Marion Cornick Co-founder & Chair of Directors Liaise LoddonMarion Cornick, Chair of Directors

Our Work in Zambia – Supporting children with special needs

DSCN1603Zambia one of the poorest countries in the world situated north of South Africa and south of the Sahara Desert. Zambia was once a British colony but has been independent for fifty years – but struggles to provide health care and education with limited numbers of professionally trained people.

It is usual for example to have one teacher with a class of 95 junior age children. Interestingly the children learn as well as children in the UK as they are desperate to have an education.

Marion was asked to go and give some support to the school which is in the grounds of the University Teaching Hospital (UTH) and there are around 250 children in the school with various disabilities and especially autism, cerebral palsy and hearing impairment. The school is staffed with teachers who have some training and it is common for them to have 30 children in a class with no assistants at all. Imagine that in this country!
MC, GR, JY

Marion, Deborah, Georgina and Joanne have been there to give the teachers extra training and especially in communication,  positive behaviour support, classroom management, and PROACT-SCIPr-UK®.

Interestingly they do not need much training in physical interventions as the children are generally well behaved and compliant. However they do need lots of support in understanding autism, how to communicate using pictures and signing, and how to organise their days in school.

We have used some ideas from TEACCH to help with organising areas of the classroom to be for specific activities such as a story corner, a sensory area, water play, music activities, and an area for the class to take part in group activities.

We have spent time teaching the staff how to make equipment using boxes and packaging which are free – and it is great to see how inventive the teachers can be with lots of games and story books and bags to help equip the little library we have set up for them.

parachute 2
Two teachers are now attending university to get qualified in special education and we have been asked to work with the university on our net visit. We now have six teachers who are PROACT-SCIPr-UK® instructors.

Our fundraising both at Loddon and Liaise help with the expense of travel to Zambia and also the cost of the University courses. The Rotary Club of Basingstoke Deane has helped us with these fees and the repair of the school’s minibus. The teachers could not afford the training without our help as everything is very expensive and most people live on low income and many on ‘the dollar a day’.

Kidsfrom UTH-4One little boy in the school has serious difficulties with autism and for the past three years we have only seen him running around and trying to get hold of mobile phones. But on our last visit he wrote a note to us saying ‘I want the book please’ meaning the iPad.

Staff had recently observed him writing and asking for things – we never know what is going on with our children so need not be surprised if they suddenly show that they can read and write. No one had taught him and he really enjoyed working on Joanne’s iPad! He has a wide vocabulary and although not able to talk can now write down what he wants and needs.

IMG_0136Peter has cerebral palsy and cannot support his body at all –  but is very clever – but has no specialist equipment to help him! In the UK he would be in school with lots of technology aids and a teaching assistant.

We have just managed to get him a laptop and he is working on it with his brothers – so some real freedom for him. At the beginning he was just lying on the concrete class room floor facing the wall – not very stimulating!

There is much to do, but the teachers are keen and excited by all we are able to share with them. and as the  teachers learn now to give added skills to the children so the children will learn and have a better chance in life. Education is so important – without it the country will never succeed.

‘It is better to teach a man to fish than to give him fish to eat’

If you want to help talk to Marion and she will give you some ideas of way you can help the project.

Marion CornickKidsfrom UTH-2