The following case study illustrates how an NHS Trust worked in consultation with Positive Response to support a service user with a history of engaging in severe challenging behaviour. The case highlights how, within a framework of Positive Behaviour Support, the use of restraint was reduced and the service user’s quality of life was improved.
Jane is a 35 year old service user with Autistic Spectrum Disorder and enduring challenging behaviour. She has been supported within residential services from early childhood and throughout her adult life. Jane was known to engage in a range of complex challenging behaviours that were presented at extremely high frequency and were of high intensity. The behaviours of greatest concern were self injurious behaviour which consisted of slapping and punching herself in the head with enough force to break the scalp. Physical aggression was also directed towards others and consisted of biting, kicking and striking carers.
Historically responses to these crisis behaviours were largely reactive with upward of 30+ floor based restraints per day and extended, frequent periods of seclusion being implemented. Through her life Jane had been exposed to a wide variety of physical and non-physical interventions in an effort to manage the behaviours.
The staff team supporting Jane struggled to understand that her behaviour, though at times bizarre and puzzling, may be functional for her and had fallen into a cycle of restrictive interventions.
Jane was living in a care environment that was not suited to the supporting her needs. Whilst she had her own bedroom, she shared a communal living space with three other individuals who themselves presented with difficult behaviours and one that was highly staffed therefore creating a busy, at times noisy, environment. There were very few opportunities for activity within the care setting and due to previous incidents in the community Jane was no longer accessing community based activity.
The multi-disciplinary team (MDT) approach was undertaken, working to explore how the frequency of these incidents may be reduced. As part of this, the existing care setting was decommissioned and Jane moved to a purpose designed unit where she shared a bungalow with just one other service user. Despite this positive move the frequency and intensity of the target behaviours and reactive strategies remained at an unacceptably high level.
Positive Response was consulted regarding the level and nature of the interventions. They visited the unit on a number of occasions to assess the support package already in place and to advise on strategies for reduction in the use of restraint. Reassurance was also sought from Positive Response regarding the strategies already being put in place as a part of the MDT approach.
A comprehensive functional analysis of the behaviours of concern was completed. This included an assessment of Jane`s immediate living environment, activity opportunities, level of skills and a mediator analysis. This analysis resulted in the hypothesis that the behaviours had a function of seeking sensory input. It was apparent from the data collected that Jane was seeking restraint in order to gain deep pressure sensation via the use of restrictive holds. This reflected a history of previous interventions that were traced back to Jane’s childhood whereby at times of crisis she was wrapped to help her calm thus providing a deep pressure sensation.
Following this assessment a number of positive changes were made to Jane’s support plan. Service user focused staff training was provided giving the care team a more in depth understanding of Jane and her behavioural triggers. It enabled them to respond consistently and proactively to early behavioural indicators, therefore reducing the likelihood of crisis. Significant environmental changes were made which included the provision of a richer activity schedule.
Using the outcomes of the functional analysis which suggested a sensory element to behaviours, occupational therapists developed a program which facilitated a functionally equivalent intervention. This consisted of a weighted blanket being used by Jane proactively, both when at baseline and at times of increased arousal to facilitate deep pressure sensation which had previously only been achieved via restraint.
As a result of these interventions there has been a measurable, consistent reduction in the use of restrictive physical interventions over a long period which to date remains at a stable low level.
Jane enjoys an enhanced quality of life as a result of greater access to activities both within her home and in the community. Where Jane previously had no access to the community she now regularly shops for food and clothing, eats out and cooks her own meals.
One important side effect of the reduction of behavioural incidents is the positive impact on they way Jane is viewed by others. Whereas Jane previously had a negative reputation, in the main being known for her complex behaviours, she is now viewed much more positively and her abilities embraced.
Over time the importance of maintaining the support plan has been highlighted, particularly when behaviours of concern are of such a complex nature. Without regular reviews and a consistent application of the plan the behaviours will return.
2gether NHS Foundation Trust