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September 14, 2012 Sarah Ailey PhD RN CDDN APHN-BC Arlene Michaels Miller PhD RN FAAN

Implementing the Steps to Effective Problem-solving Program in Group Homes Among Individuals With Intellectual Disabilities and Their Staff. September 14, 2012 Sarah Ailey PhD RN CDDN APHN-BC Arlene Michaels Miller PhD RN FAAN Tanya R. Friese MSN RN Research funded by:

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September 14, 2012 Sarah Ailey PhD RN CDDN APHN-BC Arlene Michaels Miller PhD RN FAAN

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  1. Implementing the Steps to Effective Problem-solving Program in Group Homes Among Individuals With Intellectual Disabilities and Their Staff September 14, 2012 Sarah Ailey PhD RN CDDN APHN-BC Arlene Michaels Miller PhD RN FAAN Tanya R. Friese MSN RN Research funded by: Rush University College of Nursing #31202

  2. Purpose 1.Describe a pilot program implementing a preventive community-based social problem solving program among individuals with ID and their staff 2. Discuss the potential of using the support environment of group homes to assist individuals with ID to maintain and use learned social problem-solving skills.

  3. Background Aggressive/challenging (problem) behaviors • Destructive, disruptive, socially offensive, unusual/repetitive, withdrawn/inattentive, and uncooperative behaviors that can be harmful or cause disruption to self and/or others1 • Consequences - loss of programming, psychiatric hospitalizations, incarcerations2-5 • Increase costs • Public health problem for individuals with intellectual disabilities (ID), their families and supports

  4. Problem behaviors in group homes • Over 400,000 live in small group homes- Increase >300% over last 20 years6 • 20-25% residents report distress from other residents’ problem behavior7,8 • Residential staff members often do not know how to manage; respond in ways that reinforces problem behaviors9,10 • Punitive methods dangerous and unacceptable to human rights11,12 • Agencies encouraged to promote positive behavior support.13

  5. Social problem-solving • Social problem-solving (SPS) • cognitive & behavioral processes of solving problems • two independent, interrelated dimensions: attitude & style14 • Deficits increase susceptibility problem behaviors14,15 • Previous research • SPS training in clinical and forensic settings - positive results on behaviors16-18 • Outcomes better if accompanied by staff19 • Independent action did not increase16 • Needs to translate as preventive interventions in community that might provide support for maintaining and using SPS skills

  6. Group home support system • Group homes setting can • promote social networks & • contribute to quality and security of life20 • Residential staff members • provide support and assistance with needs21 • Some report relationships with residents as a source of satisfaction, view jobs as a calling21 • Need to improve support system of group homes and reduce problem behaviors

  7. Steps to Effective Problem-solving • Based on research-based SPS program14 • Developed for group home setting using multiple sequential methods22 • input from supervisory staff responsible for behavioral programming for individuals with ID • cognitive interviews among individuals with ID and residential staff members • Pilot of program in two group homes • Follow up interviews individuals with ID & residential staff

  8. STEPS • Number of modules reduced to 6 (12 in original)22 • positive attitude toward problems, • situations likely to lead to problem behaviors • rational problem solving behaviors including defining problems, developing alternative solutions, and predicting consequences of rational responses vs. problem behaviors. • Training in stopping, slowing down, thinking and acting integral part of the program23 • Interactive exercises, role-play, card sorts, practice exercises, electronic media components • Didactic material minimized • Materials to develop group environment • Advice on where and when obtained22

  9. STEPS STEPS is designed to systematically build on the ongoing relationship between residential staff and individuals with ID in the group homes and the relationships between the residents as a means of assisting individuals with ID to maintain and use learned social problem-solving skills.

  10. STEPS Pilot study The purpose of this study was to 1) assess the feasibility of delivering STEPS as a preventive intervention to reduce problem behaviors in group homes 2) evaluate the initial efficacy of STEPS.

  11. STEPS Framework

  12. STEPS Framework • Based on • Interaction Model of Client Health Behavior24 • Relational/Social Problem-Solving Model of Stress14 • Grounded in philosophical construct of human agency25

  13. STEPS Framework Examines explanatory relationships among • determinants of problem behaviors • Depression • Life events • Age • Gender • intervention strategies • support environment for SPS skills • Residential staff SPS • Group problem-solving • Cohesiveness • outcomes of SPS skills and problem behaviors.

  14. Design: Subjects • Group home level • two group homes were recruited through one agency in a Midwestern metropolitan area • inclusion criteria - homes with at least one incident report for behaviors per month over at least three months • 33% of the residents in the homes had incident reports.

  15. Design: Subjects • Individual level • Individuals with ID • Of 14 residents in two homes • 12 agreed to participate; of these, • 9 required consent of a legal guardian • Residential staff • Six residential staff signed consents • four actually participated, two staff in each home. • One staff participant left employ of agency midway

  16. Background characteristics Individuals with ID • 7 men, 5 women • 25% minorities • Mean age 36.6 (SD 10.5) • On average, 5 life events (range 0-9)26 • Mean depression score (GDS-LD) 10.5 (SD 7.9)27 Residential staff • 4 women • 50% minorities.

  17. Feasibility • Attendance - Average Number sessions attended • Satisfaction- after each module, end of program • Fidelity - Breitenstein’s Fidelity Checklist29- from coded audiotapes of sessions • Adherence • Competence • Participation in the intervention - coded audiotapes of sessions

  18. Attendance • Individuals with ID attended 70% • men went to another location for 3 modules • Residential staff attended 67% • residential staff members were not all scheduled to work the days of the intervention.

  19. Satisfaction • Satisfaction with sessions high to very high • individuals with ID - 91% • residential staff - 87% • At final evaluation, high to very high • >80% both groups • Individuals with ID wanted more of program • Residential staff helpful aspects • training in breaking down problems • getting to know how individuals with ID relate to each other

  20. Fidelity Competence • Leaders demonstrated over 75% of the time • Skills included: • effectively responding when participants resistant • maintaining good pace for group discussion • helping anticipate challenges in using new skills

  21. Fidelity Adherence • Leader was scored over 90% for most sessions. • Strengths included: • communicating in respectful, positive, and non-judgmental manner. • non-judgemental about discussed behavioral issues such as throwing items and fighting • positive behaviors encouraged • facilitated discussion alternatives to negative behaviors.

  22. Participation Audiotapes of sessions coded for: • Participant discussion during the sessions • key concepts discussed • number of sessions each concept discussed • mean timesconcepts discussed each session

  23. Table - participation

  24. Initial efficacy • Support environment for SPS (mediating factor in conceptual framework) • Residential staff SPS • Social Problem-solving Inventory-Revised (self report)30 • Group level SPS • Group-level problem-solving scales of Iowa Family Interaction scales (IFIRS)31 • Cohesiveness • Cohesiveness subscale Group Environment Scale22

  25. Support environment for SPS Residential staff SPS • Improvement Effect size of d=.62 • Mean scores increased from 69.7 (SD 7.25) to 74.0 (SD 6.6) Group SPS • Improvement in group-level problem solving was d=.78 (pre and post-intervention). Scores increased from 15 (SD 1.4) to 17.5 (SD 4.9) Cohesiveness • Effect size for improvement in cohesiveness was d=1.43 (first session to last session). Scores increased from 28.5 (SD .71) to 30.0 (SD 1.4).

  26. Outcomes: SPS skills individuals with ID • Individual-level Problem-solving Scales of IFIRS- Coded videotape (outside evaluator) • Effect size for improvement in was d=.55. Mean score on the Problem-solving Scales increased from 8.8 (SD 4.8) to 11.7 (SD 5.8)31 • Problem-solving Task17-coded audiotape (self-report) • Effect size for improvement on Problem-solving was d=.59. Mean scores increased from 42.4 (28.1) to 59.4 (SD 29.1).

  27. Outcomes: Behaviors individuals with ID • Dyadic Interaction Scales of IFIRS (negative behaviors)31 Coded videotape (outside evaluator) • behaviors include: hostility, verbal attack, physical attack, contempt, angry coercion, hostile escalation, reciprocal hostility, dominance, lecturing/moralizing, interrogation, denial. • The effect size for decrease in problem behaviors was d=1.32 for individuals with ID.Scores decreased - mean 17.9 (SD 4.7) to12.5 (SD3.5)

  28. Conclusion • STEPS pilot showed • reasonable attendance and satisfaction with the program • Intervention fidelity • participants discussed key concepts • As in the previous research, effect sizes • indicated improvement in social problem-solving and behaviors for participants with ID.

  29. Conclusion • Important incremental advance • addressed support environment for social problem-solving • Despite small sample size, effect sizes indicate support environment might be improved with interventions • A larger study is necessary • address whether improvements in support environment can assist individuals with ID to maintain and use learned SPS skills • whether approach prevents problem behavior • can costs of problem behaviors be reduced

  30. References • Royal College of Psychiatrists (2001) DC-LD [Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation]. London: Gaskell Press. • Barron, D. A., Hassiotis, A., & Paschos, D. (2011). Out-of-area provision for adults with intellectual disabilities and challenging behaviour in England: Policy perspectives and clinical reality. Journal of Intellectual Disability Research, 55, 832-843. • Cooper, S.A., Smiley, E. Jackson, A., Finlayson, J., Allan, L., Mantry, D. & Morrison, J. (2009). Adults with intellectual disabilities: prevalence, incidence and remission of aggressive behaviour and related factors. Journal of Intellectual Disability Research, 53, 217-232.

  31. References 4. Lunsky, Y., & Palucka, A. (2004). Depression and intellectual disability: A review of current research. Current Opinion in Psychiatry, 17, 359-363. 5. Nichols, M., Bench, L., Morlok, E., & Liston, K. (2003, April). Analysis of mentally retarded and lower-functioning offender correctional programs. Corrections Today Magazine, April, 119-121. Retrieved from http://www.highbeam.com/doc/1G1-123670517.html http://www.allbusiness.com/public-administration/justice-public-order/1143300-1.html 6. Salmi, P., Scott, N., Webster, A., Larson, S. A. & Lakin, C. K. (2010). Residential services for people with intellectual or developmental disabilities at the 20th anniversary of the Americans With Disabilities Act, the 10th anniversary of Olmstead, and in the Year of Community Living. Intellectual and Developmental Disabilities, 48, 168-171. PMID: 2059775208. Accessed January 31, 2012.

  32. References 7. Ailey, S. H. (2007). Sensitivity and specificity of depression screening tools. Unpublished data. 8. O'Rourke, A., Grey, I. M., Fuller, R., & McClean, B. (2004). Satisfaction with living arrangements of older adults with intellectual disability: Service users' and carers' views. Journal of Learning Disabilities, 8, 12-29. 9. Rose J.L. & Cleary, A. (2007) Care staff perceptionsof challenging behaviour and fear of assault. Journal of Intellectual and Developmental Disabilities, 32, 153-161. PMID:17613686 10. Whittington, A., & Burns, J. (2005). The dilemmas ofresidential care staff working with the challenging behaviour of people with learning disabilities. The British Journal of Clinical Psychology/The British Psychological Society, 44(Pt 1), 59-76. 11. Tumeinski M. (2005). Problems associated with use of physical and mechanical restraints in contemporary human services. Ment Retard.;43(1):43-47. PMID:15628932 http://www.srvip.org/restraint_article_feb_2005.pdf

  33. References 12. Weiss EM, Altimari D, Blint DF, Megan K. (1998). Deadly restraint: A Hartford Courant investigative report. Hartford Courant. • Sandomierski T, Kincaid D, Algozzine B. Response to intervention and positive behavior support: Brothers from different mothers or sisters with different misters?http://www.pbis.org/news/New/Newsletters/Newsletter4-2.aspx. • 14. Nezu CM, Nezu AM, & D’Zurilla T. Problem solving therapy: A positive approach to clinical intervention(3rd ed.). New York: Springer Publishing Co. 2007. 15. McGillivray JA, McCabe MP. The relationship between residence and the pharmacological management of challenging behavior in individuals withintellectual disability. J Dev Physl Disabil.2005;17(4):311-325.

  34. References 16. Loumidis, K., & Hill, A. B. (1997). Training in groups with intellectual disabilities in social problem solving skills to reduce maladaptive behaviour: The influence of individual difference factors. Journal of Applied Research in Intellectual Disabilities, 10, 217-238. 17. Nezu, C. M., Nezu, A. M., & Arean, P. (1991). Assertiveness and problem-solving training for mildly mentally retarded. Research in Developmental Disabilities, 12, 371-386. 18. Taylor, J.L., Novaco, R.W., Gillmer, B.T., Robertson, A., & Thorne, I. (2005). Individual cognitive-behavioural anger treatment for people with mild-borderline intellectual disabilities and histories of aggression: A controlled trial. British Journal of Clinical Psychology, 44, 367–382. 19. Rose, J., Loftus, M., Flint, B., & Carey, L. (2005). Factors associated with the efficacy of a group intervention for anger in people with intellectual disabilities. The British Journal of Clinical Psychology / the British Psychological Society, 44(Pt 3), 305-317.

  35. References 20. Robertson, J., Emerson, E., Gregory, N., Hatton, C., Kessissoglou, S., Hallam, A., et al. (2001). Social networks of people with mental retardation in residential settings. Mental Retardation, 39(3), 201-214. 21. Ailey, S. H., O'Rourke, M., Breakwell, B., & Murphy, A. (2008). Supporting a community of individuals with intellectual and developmental disabilities in grieving. Journal of Hospice and Palliative Nursing, 10(5), 1-8. 22. Ailey, S.H., Friese, T.R., & Nezu, A.M. (2012). Modifying a social problem-solving program with the input of individuals with intellectual disabilities and their staff. Research in Nursing and Health, Article first published online: 2 JUL 2012. lDOI:10.1002/nur.2149 23. Tasse, M (2006). Functional behavioral assessment and mental retardation: Evolution towards considering the function of problem behaviour. Current Opinions in Psychiatry, 19, 475-480.

  36. References 24. Cox, C.L. (2003). A Model of health behavior to guide studies of childhood cancer survivors. Oncology Nursing Forum, 30(5), E92-9. PMID:1294960 25. Bandura, A. (2001) The changing face of psychology at the dawning of a globalization era. Canadian Psychology/ Psychologie Canadienne, 42, 12-24. 27. Moss, S., Ibbotson, B, Prosser, H., Goldberg, D., Patel, P. & Simpson, N. (1997). Validity of the PAS-ADD for detecting psychiatric symptoms in adults with learning disability (mental retardation). Social Psychiatry & Psychiatric Epidemiology, 32, 344-354. 28. Cuthill, F.M., Espie, C.A., & Cooper, S. (2003). Development and psychometric properties of the Glasgow Depression Scale for people with a learning disability: Individual and carer supplement versions. British Journal of Psychiatry, 182, 347-353.

  37. References 29. Breitenstein., S.M, Fogg, L., Garvey, C., Hill, C., Resnick, B., & Gross, D. (2010). Measuring implementation fidelity in a community-based parenting intervention. Nursing Research, 59, 158-165. PMID:20404777 30. D'Zurilla, T., Nezu, A.M., & Maydeu-Olivares, A. (2002). Manual: Social problem-solving Inventory—Revised (SPSI-R). North Tonawanda, NY: Multi-Health Systems. 31. Melby, J.N., Conger, R., Book, R., et al. (1998). The Iowa family interaction scales (5th ed.). Ames IA: Institute for Social and Behavioral Research. 32.Wilson, P.A., Hansen, N.B., Tarakeshwar, N., Neufeld, S., Kochman, A., & Sikkema, K.J. (2008). Scale development of a measure to assess community-based and clinical intervention group environments. Journal of Community Psychology, 36, 271-288.

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