INTRODUCTION

1. INTRODUCTION • Over a third of individuals with Intellectual Disability under care of local authorities reside in out of borough placements (Whelton, 2009, see: McGill et al, 2010). • Prominent in this group are individuals who exhibit behaviour that presents a challenge to services (Emerson & Robertson, 2008, see: McGill et al, 2010). • Out of borough placements are often high cost and of dubious quality. • Such placements often occur as a reaction to crisis situation.

2. Case Study: Anna • Anna is an adult with a learning disability • Anna was placed in an out of borough residence, due to a lack of local expertise in supporting people whose behaviour challenges • The out of borough placement was of dubious quality, yet very costly • Anna lived in an isolated environment, detached from typical community living • Some evidence of restrictive practices was observed in the setting • Opportunities for engagement in leisure, domestic and social activities were extremely limited

3. Case Study: Anna • Anna was unoccupied for long periods of time • She engaged in regular, high levels of undesirable behaviours, including: • Aggression towards staff • Undressing in inappropriate situations • Urinating inappropriately • No consistent behaviour interventions were being used • Anna was prescribed with significant amounts of medication, in an attempt to control her behaviour

4. Anna’s Previous Home and Surrounding Area:

5. The Mansell Report: • The Mansell Report (Revised edition: 2007) recommends specialist challenging behaviour services (a) work intensively with a small number of individuals and (b) help strengthen mainstream services so they can serve people locally. • Research on specialist Challenging Behaviour services suggests effective services are likely to be: • Peripatetic • Psychology-led, • Have good case management procedures • Clearly orientated to evidence-based approaches in behaviour analysis (Forrest et al. 1996).

6. Halton Borough Council: • Halton Borough Council alongside Halton CCG have commissioned a specialist peripatetic challenging behaviour support service. • Neighbouring authorities Knowsley and St Helens Council/St Helens CCG are also commissioning the service. • The Positive Behaviour Support Service (PBSS) is an invest to save service.

7. Positive Behaviour Support Service (PBSS): • The PBSS is a cross-borough, Local Authority led, lifespan (adult’s and children’s) service. • It is the first in the UK to be staffed and led by Board Certified Behaviour Analysts (BCBA) • The Behaviour Analysis Certification Board (BACB ®) certifies and regulates behaviour analysts. Over the last ten years there has been a steadily increasing demand across Europe for Board Certified Behaviour Analysts (BCBA: Hughes & Shook, 2007).

8. BCBA status: • BCBA certificate holders have at least an MSc in Applied Behaviour Analysis from a BACB approved course. • 1500 hours minimum supervised work experience, with at least 75 hours of contact supervision from a BCBA is also required. • Ongoing clinical and professional development is required to maintain the BCBA qualification. • This is done by obtaining Continuing Education Units. • BCBA holders are required to abide by stringent professional and ethical guidelines.

9. Functional Assessment: • Behaviour Analysts conduct Functional Assessments. • Functional assessment is the gathering of specific information to help understand a challenging behaviour. • A full functional assessment covers several categories of information. • For example: Problem behaviour, antecedent and consequence events, alternative behaviours, motivational aspects and reinforcer potential and previous interventions. • A Functional Assessment can be indirect (interviews, rating scales etc); direct (observations etc) and experimental (purposeful manipulation of environmental variables).

10. Core Aims of the PBSS: For the individual service users… • Improved quality of life • Increased opportunity for meaningful engagement • More opportunity for education/cognitive development • Increased opportunity for community participation • Greater access to a less restrictive environment • Improved relationships

11. Core Aims of the PBSS: For those caring for or supporting individual service users… • Reduced stress • An increased knowledge and understanding of behaviour function, environmental and stimulation effects • An increased efficiency during times of problem behaviour occurrence • Improved relationships with service user • An increased confidence in ability to cope • A feeling of being supported.

12. Core Aims of the PBSS: Overall risk reduction… • Damage to health and social well being • Personal injury • Placement breakdown • Out of borough/restricted placement • Reaching crisis point • Damaged relations • Preceded by one’s case history • Intrusive support levels • Normal life opportunity limited by over zealous risk assessment • High cost placement/support packages

13. Service Aims: • The service will work collaboratively in four related areas: • Early Intervention • Crisis Prevention and Management • Technical support • Placement Development.

14. Early Intervention: • The PBSS will provide an Early Intervention service to high risk groups e.g. children with Autistic Spectrum Conditions. • Early intervention work will consist of: • Parent/Carer training workshops • Work with individuals • Close working with schools

15. Crisis Prevention and Management: • The PBSS will have a prominent focus on crisis prevention and management. Such work will include: • Developing mainstream service staff competencies and mentoring • Mechanisms for surveillance i.e. behaviour monitoring, early identification of potential behaviours that may present challenges to services. • Prevention of placement breakdown and out of borough placement • Eligibility criteria for crisis situations • Single and multiple consultations

16. Crisis Prevention and Management: • The PBSS will also aim to have presence at key risk times For example: • Transition from children to adult services • Staff change over • Placement change e.g. changing schools, transition in to a new placement such as day services.

17. Technical Support • The PBSS will provide specialist individualised treatment for the most complex cases. This will include: • Referral, review, and allocation for full functional Assessment • Person centred intervention plan • Clear service exit preparation • Follow up and maintenance (Linking back into crisis prevention and management) • Placement Development • A core aim of the PBSS will be to return people who are currently out-of-borough to their local area.

18. Potential Challenges: • Resistance • Referral pathway complications • Competing priorities • Professional rivalries • Immediate financial pressures (invest to save)

19. TRAINING: The PBSS aims to provide effective training for parents/carers and staff supporting individuals e.g. supported housing staff/teachers/day service staff. • ACTIVE SUPPORT • Engagement • Engagement is defined as (a) participating in a constructive activity e.g. laying the table, and (b) social interaction e.g. having a conversation and participating in group activities (Mansell et al, 2005). • Engagement like this provides increased opportunity to develop relationships, opportunity to a more varied life experience and also give better prospects for making informed choices. • Researchers working with people with intellectual disabilities, identified two variables that influence engagement in everyday meaningful activities (Ashman, Ockenden, Beadle Brown & Mansell, 2010). • The skill level of the individual • The level and quality of support given to that individual by staff

20. ACTIVE SUPPORT (Cont’d) Engagement (Cont’d) An overall aim of active support is for staff to provide the correct level of support to individuals, so that they can engage in meaningful everyday activities(Jones et al, 2009). EVIDENCE: There is compelling evidence for benefits to individuals of implementing active support (Stancliffe et al, 2008; Totskia et al., 2008).

21. Aims of the PBSS for Anna To improve Anna’s overall quality of life by: • Enriching her living environment • Increasing her opportunities for: social interaction; leisure activities; participation in “normal” activities and personal development • Removing the restrictions placed on her physical environment • Reducing the occurrence and intensity of behaviours • Giving her alternative means of communicating her needs and expressing choice

22. Aims of the PBSS for Anna To improve the quality of support for Anna by: • Installing consistent intervention plans for behaviour reduction and skill development • Training staff in effective support strategies • Providing continuing advice and support for staff • Ongoing monitoring through data collection and analysis

23. PBSS Input The PBSS’ input to date has included: Assessment and Intervention • Functional assessment of the target behaviours • Completion of rating scales • Direct observation of Anna’s behaviours • Detailed Person Centred Intervention Plan • Contributing to transition plan for move back to Halton

24. PBSS Input The PBSS’ input to date has included: Training and Monitoring • Theory training for new staff team on the principles of Behaviour Analysis and Active Support • “On the job” training for each staff member, tailored specifically to individual training needs • Team report outlining training targets • Training in data taking • Ongoing analysis of data for informed decision making

25. Anna’s Life Now What has changed? • In January 2011, Anna returned to live in Halton • She now resides in a bungalow in a typical residential road • Anna has unrestricted access to all areas of her home • Staffing levels have reduced at certain times of the day • Staff actively plan activities across the day • Staff encourage participation in “normal activities” • Staff use less restrictive, more effective interventions

26. Anna’s Life Now What has changed? • Anna is more settled in her new home • Anna participates daily in: • Domestic activities • Leisure and social activities • Community activities • Undesirable behaviours have reduced in frequency and intensity • Anna’s staff team are confident in how to enrich her environment and effectively support her • Improved quality of life…package cost annual saving of £92, 500

27. Cost Effectiveness: • Current/Previous Cost Saving • PCT £ 244,400/year £140,000 • HBC £175,000/year £30,000 • -HBC £ 210,000 £45,000

28. Anna’s Current Home and Surrounding Areas:

29. CONTACT DETAILS: Maria Saville BCBA- Principal Manager Positive Behaviour Support Service Maria.Saville@halton.gov.uk Dr Sandy Toogood BCBA-D- Consultant Behaviour Analyst s.toogood@bangor.ac.uk Paul McWade- Operational Director Complex Care, Halton Borough Council Paul.McWade@halton.gov.uk Kath Devonshire BCBA- Practice Manager Positive Behaviour Support Service Kath.Devonshire@halton.gov.uk