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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

Gary LaVigna visits Liaise

Last week we had a visit from Gary LaVigna, co-founder with Thomas Willis of the Institute of Applied Behaviour Analysis (IABA) in Los Angeles. The IABA was created to provide the most advanced and highest possible quality services to support people with developmental disabilities. Their training programme is based on the multi element model of positive behaviour support (PBS) which was adopted and integrated alongside PROACT-SCIPr-UK® by Liaise Loddon to form the basis of our own  positive behaviour support model.

Gary LaVignaGary delivered a talk to Liaise managers and specialist workers on functional analysis and focused support plans and gave us advice and tips on how to effectively implement successful support programmes. There was also a discussion on ensuring consistency in delivery by support teams and measuring outcomes.

The session re-energised us in our work to create the best possible positive and sustainable services for our service users.

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…

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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.

Sansa House goes paperless – and discovers a new use for iPods

Did you know that iPods are good for much, much more than simply playing music?

We didn’t – until recently. But now they’re changing the way we do things at Sansa House and they’re a big hit with everyone: the people we support, our staff, and our directors.

A few months ago, we took up a free trial of Person Centred Software. We were impressed, so it’s just gone live at Sansa House.

So far, the staff are really positive and believe that it’s a great modernising step for them. It also makes their jobs simpler, because they’re able to more easily monitor the people they support. Plus, there’s much more space for diary entries so there’s much more information available about the people we support and everyone can access it.

What does Person Centred Software do?

Person Centred Software (PCS) created Mobile Care Monitoring, which gives staff more time for care – because they spend less time on administration and they have more information about the people they support when they need it.

Essentially, it gives us a better picture of how the people we support spend their days and nights. And that allows us to keep improving their lifestyles.

And how do iPods fit in?

At Sansa House, we’ve chosen to use PCS with our iPods. The software sits on the iPods and goes everywhere with our staff. It’s proving really useful for all kinds of things, from the vitally important stuff right down to little fun touches that make everyone smile.

Measuring happiness and keeping everyone in the picture

Carly sits on a chair studying her new iPod.

Carly gets to grips with the new monitoring system

We’re using our new system to measure happiness every day, with positive monitoring. They make it easy to analyse participation in activities over time, so we can build a picture of our service users’ lifestyles. Identifying trends and patterns means we can tell who takes part in what, and find out which activities each individual prefers. That makes it very easy to create tailored programmes for all the people we support.

All our service users’ schedules are on the iPods now, and the staff are find that extremely useful. They can easily:

  • Check which tasks are upcoming for each person they support
  • Flag important tasks, such as when medication is due
  • Add extra information about each service user as and when it comes up
  • Take more pictures! The iPod camera is easily accessible, so we’re taking many more photographs of the people we support doing the things they enjoy (and they love photos of themselves)

But perhaps most exciting is the fact that all this information is available to ALL registered users through a weblink. Liaise’s managers and directors now have a full and immediate picture of what’s going on at Sansa, so they can make sure that all staff have everything they need.

In every industry, there tends to be a gap between management and the people who work in the field. Our gap was pretty small anyway – but now we’re hoping to close it completely. It’s so important for everyone in the organisation to feel involved in our everyday activities and stay close to the people we support.

The verdict? So far, we’re loving it! Watch this space to see if we roll it out to all our houses.

If you’d like to know more about how we’re using Person Centred Software, just give us a call on 0845 094 9295 and we’ll happily talk you through it.

And remember to sign up to our free newsletter if you haven’t already – we’ll keep you up to date with the latest news from our homes, and advice and information about autism and learning difficulties.

Supporting Disabled Children in Zambia

In association with The Rotary Club of Basingstoke Deane, Liaise Loddon are planning to support a school in Lusaka, Zambia. It is our aim to help the school there for disabled children – bring them something of the Liaise Loddon and Loddon School philosophy and approaches.

We recently entertained Dr Ravi Paul from Zambia as a result of our connection with Dr. David Percy who has been a school trustee. David works as an adviser to THET (Tropical Health and Education Trust) and Ravi is the only psychiatrist in Zambia where there are 13.2 million people. Ravi was very excited by the work in the school and in Liaise and wants to develop the school in Lusaka using the same positive supports individualised philosophy.

We want to do the work so it does make a difference – so Marion is currently in Zambia to see the school and the scope of the training we need to give to help them. This will be similar to the work that the Loddon School has been doing in Romania and Azerbaijan for many years.

An exciting challenge to support children who really need something better. We will send more information as we make progress and want it to be a real success story in a very poor part of the world.