Introduction
This dissertation will help the author to increase knowledge about literature review that supports on how to understand and manage clients with Learning Disability and Difficult Behavior. The support worker conducting this research is currently studying at University of Winchester. Taking BSc(Hons) Professional Practice in Health and Social Care. Have been working in a residential home in North London caring for clients with learning disability and autism. Basically we support the client to improve their living and help them live independently as possible. I have been working as a support worker for almost a year now. And as a support worker it is my responsibility to provide best quality care to the clients I am supporting from the very basic such as helping in personal care and domestic responsibilities. We support our clients using their personal care plan, which provides information about client’s preferences that is compiled by the company. To familiarize to the clients support plan and strategies and following guidelines in implementing daily activities. Including medicine protocols, video tracking of structured teaching plans and giving time out strategies in dealing aggressive behaviour. The reasons for these study is to educate people about learning disability, to understand and improve approaches in dealing challenging behaviour and at the same time help these clients to overcome difficult behaviour. The study will also help future researches to update and apply new developments in dealing difficult behaviour with these clients.
The selected topic to be discussed is managing clients in difficult behaviour using effective interventions. Practices that will help manage difficult situations, helping clients with learning difficulty to overcome challenging behaviour and improving support for people with learning disabilities. To start with, there are many kinds of learning disabilities that involve a person’s way of thinking. The manner our brains develop information is compound and make someone marvel about how to figure out things. Individuals with Disabilities Education Act defined learning disability as “a disorder in one or more of the vital psychological development involved in understanding or in using verbal communication, spoken or written, that may manifest itself in a deficient ability to listen, reflect, verbalize, read, write, spell, or do mathematical analogy”(Emerson 2001 p2). It is essential for the support worker dealing with learning disability to find ways in evaluating underlying cause to properly understand on how to manage the client. Especially in cases where individual with learning disability demonstrate aggression due to deficiency in expressing their needs.
The importance of these studies is to understand people with learning disabilities and provide knowledge on how to deal with or manage the condition. “As many as one out of every five people in United States ages six to twenty one has learning disability, and over half of all children who receive special education have the condition” according to (Twenty-fourth Annual Report to Congress, U.S. Department of Education, 2002). However, a child that has difficulty in reading, speaking, listening, and writing should be evaluated. “People with learning disabilities have a reduced ability to understand new or complex information, and those who experience difficulties when handing out information may find it tough to study new skills”,( DH 2001).
When a person is having learning disability he or she may have difficulty learning the alphabet, rhyming words, or relating letters to their sounds. May make many mistakes when reading aloud, do not comprehend what he reads. May have real trouble with spelling, cluttered handwriting and struggle to articulate ideas in writing. May learn language late with restricted words, difficulty remembering sounds that letters make. May have difficulty following instructions and organizing judgement he needs for writing or discussion. May not follow social policy of discussion and not be able to repeat a story in order. If a person is struggling to do any one of these skills he or she may need to be evaluated to see if he has a learning disability. However, one of those problems faced by social worker and support worker is managing difficult or challenging behaviour. Lack of experience, training or skills in managing carefully and effectively difficult behaviour could cause serious implications. “The recent intervention of choice for challenging behaviour is based on behavioural ideology and should categorize the purpose of the target behaviour and train functionally equal adaptive skills” (Ball et al 2004, Feldman et al 2004 p28).
Through these studies the author may incorporate and provide methods and knowledge to people in understanding learning disability. Find ways in managing difficult behaviour and interventions to be applied and improve support for learning disability clients. Following the introduction of this topic is literature reviews of the chosen topic in managing and understanding Learning Disability with difficult behaviour.
Search engines used
To be able for the author to go through with her dissertation the used of informational tools such as searching related to the topic was carefully selected. The author looks first on defining her chosen topic using previous journals, articles, and researches with the help of online search. By using the words learning disability, challenging behaviour and related issues therefore to answer the authors question in doing the study was searched. The use of academic source and databases online at the University of Winchester, such as British journal of Intellectual Disability, was a big help for the author in doing her dissertation. Going through and reading relevant issues have help in choosing the right literatures which the author had included in her dissertation. The author also focused only on the issues that can be useful which on the future can be used and apply in the area of practice.
Literature Review
Review of current literature regarding managing and understanding learning disability and difficult behaviour was compiled through using previous researches, journals and articles by using online research databases, British journal of Intellectual Disability at the University of Winchester.
This article entitled, Difficulties faced by social care staff when managing challenging behaviour. Upon reading this research article it says that most individuals with learning disability live in community settings supported by social workers and staff. A comparatively high ratio of individual who displays challenging behaviour (Emerson et al 2000) but may not have the practice, trainings or skills to supervise safely and effectively. Will has serious implications for client, for the workforce and eventually for service costs (Feldman et al 2004). Moreover, these issues must be addressed at an individual, group and organisational level (Gentry 2001). Severely challenging behaviour is commonly defined as, ‘behaviour of such force, regularity, or length, that the physical security of the person or others is placed in grave threat, or behaviour which is likely to badly limit, or deny access to and use of ordinary community facilities’(Emerson et al 1988). Though management of a challenging behaviour is based on identifying the target behaviour by educating functionally comparable adaptive skills but they are rarely used in an organized way. Feldman et al (2004) stated that, without formal behaviour al guidelines, staff can use involuntary, controlling and repeatedly intrusive methods to deal with challenging behaviour.
The use of improper, conflicting or reactive intervention strategies may, in turn, perform as contributing factors to an increase in challenging behaviour. In their study, McKenzie et al (2005a) found that sixty five percent of the services had complexity in implementing behavioural guidelines. These may be due to lack of time running to discuss with other staff or some matter of fact issues or dissimilar and not related to the behaviour. It can also be barriers such as lack of communication, attitudes and supervising styles. However, it is suggested to certify lasting changes in practice, improvements in service stipulation requires to be addressed at an organisational level (Gentry et al 2001, La Vigna et al 1994).
One method of doing this is the Periodic Service Review (PSR), this aims to achieve, and sustain, a high quality and constant service and has four components. Periodic Service Review was implemented regularly by an organisation providing residential, respite and family support to people with a learning disability, to help classify areas where provision quality could be improved. Firstly, is the Performance Standards, these are evident and measurable and align with the service quality can be calculated. Secondly, is the Performance Monitoring, these comprise ensuring staff recognition of the monitoring system. Thirdly, Performance Feedback, these guarantee ongoing development and maintenance of quality. Lastly, the Staff Training, this identifies the required skills and awareness staff need. The present study, thus aims to broaden the work of McKenzie et al (2005a), which recognized barriers to implementing behavioural guidelines reported by support staff, by measuring actual staff preparation in relation to these guidelines using Periodic Service Review (PSR). The aim of these article is merely finding a way to improve and compare the difference of services who uses formal guidelines and does who do not to target difficult behaviour and eventually come up to a strategy in dealing with it.
This research explains that in order to deliver a quality service to clients with learning disability we must target specific strategies to the behaviour by implementing behavioural guidelines. By setting performance standard, monitoring and trainings which will support staff to avoid reactive, controlling and intrusive methods in managing clients showing difficult behaviour. Contributing factors such as inconsistent, reactive approach and strategies could lead to escalating the client’s behaviour. Thus, could not help in finding the target behaviour and apply specific strategy as it was mentioned that in order to come up to a way to deal difficulty is to address the need to find the cause of aggression.
Another literature from an article entitled Wide-scale implementation of a support program for parents of children with Intellectual disability and difficult behaviour that in managing learning disability and complex behaviour among children shows an enormous impact on parents. Children with an intellectual disability may exhibit high levels of difficult behaviour, such as hostility, self-injury, or damage to property. Such behaviour can be a foremost source of stress for family members (Hastings, 2002, Plant and Sanders, 2007a). In recent years numerous educational programs have been developed to help parents in supervising their kids with intellectual disability. However, there is a slight enquiry that has been conducted on carrying out of interventions for families with children with disabilities.
The Signposts for Building Better Behaviour program was developed by Hudson et al (2001), and consists of a number of parent and expert equipment. The parent materials include eight guidance booklets about various aspects of managing difficult behaviour of children, a workbook, and a videotape to demonstrate the content of the booklets. The practitioner materials enclose a detail instruction guidebook on program delivery and equipment for the regular assessment of outcomes. The program can be delivered by means of several modes, namely, with face to face support to an individual family, with face to face support to a group, with telephone support to the individual, to the individual or self-directed. Which the extend of release is six sessions over approximately 12 weeks.
The Signposts program is designed to be a universal preventive program for parents of children with an intellectual disability in the age range of 3-16 years. The basic aim is to teach parents skills to direct difficult behaviour of their child before those behaviours rise to a level that require extremely intensive intervention by professional services. The approach is to teach strategies to parents that will facilitate them to develop their own action plan precisely to the individual needs of their child. The wide-scale implementation of Signposts for Building Better Behaviour program (Hudson et al, 2001) was evaluated using the benchmarks recommended by Wiese, Stancliffe, and Hemsley (2005). Which a total of 2,119 parents and carers participated in the program over an 18-month period. Where participants reported that they were less depressed, less apprehensive, and less hassled, were more convinced and satisfied with managing their child, and less stressed by their child’s behaviour.
This article shows how Signposts for Building Better Behaviour program helps parents to manage their children with intellectual disability. By getting support from number of parent and practitioner materials. This will teach them skills in managing difficult behaviour before it escalates and enable them to provide and implement their own action plan in dealing with their children. Though this article is showing how to manage children somehow some similarities to the first article was seen. Such as setting guidelines to manage the challenging behaviour on its onset and getting consistent in treating.
This next literature review discusses workforce development and challenging behaviour, training staff to treat, to manage or to cope. There are lots of new workforce development strategies and frameworks in the UK, in recovering and producing a capable, confident workers delivering high- quality, person-centred, and community- based services. It was exampled in this article some changes made in England, Wales and Northern Ireland the revision of Learning Disabilities Accreditation Framework (LDAF), replacing the current National Qualifications Framework (NQF) to Qualifications and Credit Framework (QCF). And related updates are being made in Scotland as to regulate least required qualifications at Scottish Vocational Qualifications Level III (SVQ).
These are made to improving workforce progress generally; most staff working with people with learning disabilities does not have qualifications related to their jobs. This figure may be as high as 75 percent, according to Department of Health (2001). This will make complexity in maintaining a suitable standard in delivering care to clients to meet their needs. It is stated that, community services for people with learning disability and challenging behavior are guided, in the course of policy, training, and cascading of information, to employ recommendations such as those made by BPS/RCP/RCSLT (2007). Thompson and Reid (2002) found that, ‘Behavioral symptomless is extremely persistent’. By using analyst and carer ratings behaviors measured and stereotype, over activity and emotional abnormalities were particularly persistent.
It has been said in these article that BPS/RCP/RCSLT procedures are presently the most up-to-date set of guidelines on improving the quality of life for people with challenging behavior and others around them. The role of training in disparity to evidence based for effective interventions in challenging behavior, evidence of usefulness and outcomes is weak and there is still differing evidence over the years. However, few examples of forefront staff successfully implementing useful programmers following training. ‘Therapeutic interventions to treat and manage challenging behavior are only actually effective when the belief plan and the skills of the staff member matches his performance in relation to service users’ (Ager and O’May, 2001; Campbell, 2008; Grey et al., 2007).
Though the staffs outlook on challenging behavior can be changed on a brief training an advance workplace research is needed to ascertain if change will bring stable change in the practice. Regarding priorities for staff training, the BPS/RCP/RCSLT (2007) guidelines categorized a clear set of the competencies required. And it is mentioned that they are parallel to priorities identified in the BPS Clinical Practice Guidelines: Psychological Interventions for Severely Challenging Behaviors Shown by People with Learning Disabilities (2004). Specific and demonstrable training is needed, which includes carrying out purposeful analysis, implementing and monitoring intricate treatment plans consistently in an extensive period of time. On the other hand, if the staff were to supervise challenging behavior, a diverse training emphasis is needed. The focus must be on how to reduce or prevent challenging behavior when it happens and lessen harm, without expecting that these interventions in potential occurrences are less likely.
In this article, it emphasizes the importance of training, implementing effective programmers to be able to manage challenging behavior. Service providers must be equipped with skills that match in treating the specific challenging behavior. And in addition, the British Psychological Society guidelines can be used as it is one of the most up-to-date set of guidelines on improving the quality of life for people with challenging behavior and others around them. The guidelines were also mentioned in this article which is similar to the first two articles. Although it has different contents, their focuses are the same as to managing difficult behavior.
The inpatient facilities for people with learning disabilities have almost departed over the years and have been moved to a range of community terms and support. However, in recent years a small increase of individuals who present challenge on a community based services which place them and others at danger was noticed. As Kearns (2001) stated that, “there is a distinct need for long-term care facilities for those who have an apparent need and because of the chronicity of their situation, are not suited to present medium-secure services and because of the sternness of their symptoms are not appropriate for general learning disability services”. The problem they create is hard to restrain within a typical community setting. In this article, a survey is undertaken for the need of people with learning disabilities and challenging behavior to be located in a secure care. Where restricted long stay secure service offering a series of security process and focusing on individuals that exhibits aggression and inappropriate behavior.
The independent sector has been rapid in responding to medium secure care beds and improved its short-and long-term care capability. An increasing demand for out-of-area placements by NHS providers for high quality services leads to a costly and out of place as they are distant to the individual’s home. Opposing to a target set by The National Service Framework (NHS Executive 1999) for mental health services to care for people as close to their home and community. A finding shown an almost lack of provision for individuals with learning disabilities and challenging behavior. And evidences suggest that this is a growing and continuing problem. Where it was determined a need for update in the assessment to settle on characteristics of individuals with learning disabilities to be placed in a secure service. And the development of a service design and expansion of a relevant local service, treatment (OATs) or other specialist placements.
With a high response rate to the survey, it was expected that most of the individuals with learning disability and challenging behavior who required secure care were identified. Most of the placements were in private secure setting, several miles away from the Consortium area, while private sector was competent to build up appropriate services to meet the clients need, and none of them are restricted to the consortium area. The obscurity in accessing these services is maintaining associates with families and local services or simple access in monitoring care and progress of the individuals concerned. However, the challenge in the majority of the cases was the need to control the violence and sexually aggressive behavior. And in addition appropriate curative and rehabilitative process is the center, and more vitally, services that provides outreach and sturdy links with community that facilitates regularity.
This article was somehow different from the others, especially in the way of managing the clients who shows challenging behavior. Thought it also deals with treating and managing people with learning disability and difficult behavior by placing
categorizing and placing them in a secure setting. Its focus is on providing secure care for people showing aggressive behavior to facilitate eventual return of some individual in a community-based provision.
Overall the literature sought the necessity in understanding and managing people with learning disabilities and difficult behavior is still a major problem faced by the government, agencies, care providers, and community. As Ball et al (2004), Fieldsman et al (2004) stated that the current intervention of choice for challenging behavior is based on behavioral principles and should categorize the function of the target behavior and teach functionally equivalent adaptive skills. In studying and searching for the enhancement of better interventions, strategies and administration for people with learning disability and challenging behavior was still in progress. But somehow, it was pointed out in the reviews that one of the difficulties in improving interventions is lack of ability in following behavioral guidelines. This causes intrusive, controlling and reactive approach and inappropriate strategies from care providers and carers in dealing the difficult behavior.
All reviews have given all necessary information needed by the author to understand and able to apply in practice. The reviews where helpful in comparing the interventions and strategies applied in the area of practice of the author in managing people with learning disabilities and difficult behavior. Wherein setting of guidelines was mentioned to all articles given to be followed in order to deliver a better way of dealing challenging behavior. Thought still most services fail to properly implement strategy within their area of practice.
The author is aware that all literature review included in these research is finding ways to improve the life of people with challenging behavior. These could be helpful in the progress of managing people with learning disability. As Feldman et al (2004) said that people with learning disability and challenging behavior cannot be managed by an individual alone without the necessary skills, trainings, and set of guidelines to safely deliver care to the client, as it will turn the staff to controlling and displaying a reactive approach.
Two research articles have been chosen for critical evaluation in the preceding literature review. The articles chosen will be critically evaluated in order to identify its effectiveness in helping people especially the carers dealing with learning disability and difficult behavior. First is using Periodic Service Review (PSR) in the article, Difficulties faced by social care staff when managing challenging behavior which extends the work of McKenzie et al (2005a). And the second is using The Signposts for Building Better Behavior program by Hudson et al (2001) in the article, Wide-scale implementation of a support program for parents with children with intellectual disability and difficult behavior. Although both articles were not identified as to weather a qualitative study or a quantitative study, the author finds it still helpful in producing the research assignment. And the studies are still valuable as to be critically evaluated and analyzed using differing research methodologies to compare and contrast.
Title
The Periodic Service Review (PSR) as a guideline used in the managing of challenging behaviour faced by social care workers which extends the work of McKenzie et al (2005a) shows applicable for the research content. It can be beneficial for the comparison of other approach in dealing with behavioural difficulty among people with learning disability. Hudson et al (2001) Signposts for Building Better Behaviour program, can be considerably vital in setting standard in supporting people to manage difficult behaviour. It is considerable that both studies are useful and can be applied in helping the author to find better ways to manage people with learning disability and difficult behaviour.
Abstract
The Periodic Service Review (PSR) abstract has clearly identified its use, aims, limitations and why it is used in delivering effective management for people with challenging and learning difficulty. But somehow at some point it is not clearly expanded as to whether the method was effective. Hence, the present study staff reported that though there is no difficulty in implementing the guidelines, but putting it into practice is low. As comparing the difference between services that implementing formal guidelines and those who did not use guidelines. Comparing it to the Signposts for Building Better Behaviour by Hudson et al (2001), where the study is substantial and contents such aim and question, methodology, results are present. And progress in the study was included as the result of reported response from the participants. Furthermore, it is informative and giving choices for people on how to get support in managing clients with learning disability and difficult behaviour.
Introduction/Literature Review
The Periodic Service Review as it was done randomly selecting staff on shift by the time it was carried out, I found it inappropriate in conducting a research as to disregarding consent. Though all participants’ response was confidential and the organisation assured that participation is voluntary. However, the aim of the study was clearly identifiable and well discussed and limitations were stated. A comparison between formal and informal interventions was mentioned and areas of difficulty were bullet pointed. Basically the research was able to answer aims and question and previous study was included though these article was subject for double blind review. The Periodic Service Review was used to evaluate the staffs’ approach to challenging behaviour and their outcome relevant to the previous study by evaluating the impact of training to staff practice (MacKenzie et al 2002). Somehow the study showed basis of difficulty where staff is lacking in dealing the challenging behaviour. The study was also limited lacking in statistical analysis because staff participation is diminutive to make contrast and all parts of the PSR was not conducted to working setting as to avoid disruption of clients routine. Though it may direct to some score inaccuracy the reviews were completed in a proper setting thus make factors of the study affected to be nominal. The study is typically qualitative as it provides comprehensive discussion of the topic research and explains purpose of the study.
Signposts for Building Better behaviour by Hudson et al (2001), was designed to help parents of children with intellectual disability and difficult behaviour. Partly the study is to indicate whether clinical interventions are considered as efficacy or effectiveness research. But considered as dissemination research as it evaluates strategies in spreading knowledge of new interventions and encourage in adopting the service, Sanders (2003). This research is quantitative as it provides wide survey where large numbers of participants both parents and carers participated in the program. Though the research answer aims/question and a purpose, the study is complex as it is huge type of survey and funded by organizations. As it was a long process of evaluating whether the signposts is effective and helpful in providing parents and carers in developing their own action plan in managing the difficult behaviour. Part of the study also is to evaluate participants that participate in the evaluation. As to compare outcomes from those who completed and not completed pre test, post test and follow up assessment. The research did consider ethical issue as gaining consent and participants were given anonymous identification number for the questionnaire before analysis. Indeed when compared to Periodic Service Review the latter is more complicated as many information and wide discussion of topic is considered.
Methodology
The Periodic Service Review study can be considered as cross-comparison research which to compare policies, practices, events and people as stated by Parahoo (2006). As its main purpose of the research is to monitor a consistent implementation of guidelines and service quality could be improved. Through reading this article it was hard for me to identify an appropriate research methodology, without mentioning in the discussion at the beginning even makes it harder. But based from what I have understand a semi-structured interview was conducted and score is calculated and 80 percent or above indicates service quality. Which comparisons are made between services who reported as using formal behavioural guidelines made by health professionals and those who use informal guidelines. But the study suggests that despite having the formal guidelines, still it was not implemented consistently and appropriate. Due to staff lack of knowledge and training in managing challenging behaviour. Though participants were randomly selected a questionnaire or survey was used in the study to evaluate areas where service could be improved. Parahoo (2006) and Burns (2009) suggest that questionnaires are valuable tools for research in both qualitative and quantitative data collection. Variables were not present but figures and statistics are used but groups were not analyse statistically instead descriptive statistics was used to analyse the results. On the other hand, Signposts for Building Better Behaviour by Hudson et al (2001), follows a quantitative approach due to statistical analysis, using numeric values in interpreting results. Using scale to assess and measure participant’s response as Burns and Grove (2006) says that “scale type question are more precise way of measuring phenomena”. For the result of the comparison of two groups who participate in the evaluation those who completed post test assessment and who did not, chi-square analyses and t-test was carried out.
On comparing both research articles it was not easy for the first article to identify methodology. Unlike the latter it was stated in the abstract valuable facts in the research. But thorough reading the Periodic Service Review its facts and contents will enable you to determine research purpose and intentions. As it provides clear explanation of what is the research all about which making it more interesting to read. Although the study is limited not to disrupt clients routine, all participants’ response is confidential as they were selected randomly. Thus, Signpost for building better behaviour where inclusion of only necessary data was collected, control group was not included as to previous study by Hudson et al (2003), which improves the current study.
Sample size from the first research article where 23 participants are randomly selected, thus make it more convenient for the researcher to achieve desired outcome. But none of the service achieved 80 percent acceptable level of performance, due to lack knowledge and training. Unlike the Signpost for building better behaviour where 2,119 participated including parents and carers in the program that lasted for an18 month period. Which desired outcome and result was considered successful.
Result
McKenzie et al (2005a) Periodic Service Review was explained in both descriptive and showing the range in percentage and mean of each guidelines where formal and informal approach was made to able to find or target difficulties. Wherein each care staff participated will identify difficulties by reporting as to whether formal guidelines in the setting are more helpful than those using informal strategies. But was not able to score high and reach a target of 80 percent as the suitable stage of performance, whereas, those who applies informal approach who scores high but does not able to identify difficulty and enumerate it consistently. Comparing to the result of Hudson et al (2001) Signpost for Building Better Behaviour, where intimidating and difficult to understand as it was too immense to thorough reading and interprets results of each table as to different programme stages. The difference and comparisons of tables from those parents participated for pre-test and post tests. This resulted successfully in increasing parenting efficacy wherein signposts program aim is to educate parent’s common skills in managing the behaviour of their child. Thus all family who completed Signpost where able to make and provide their own strategy and action plan in dealing their child’s challenging behaviour. The author of this dissertation was able to understand the useful ways to manage and understand the importance of assessing the level of need in trying to incorporate strategies in the clinical area. And may find it useful not only in the area of practice but people who will be interested in gaining knowledge in dealing difficult behaviour. Moreover, the writer could be able to answer question for the reasons on undertaking this dissertation and therefore share the knowledge and equally give her piece of what has been achieved based on literature reviews taken and compared.
Discussion and Conclusions
In the discussion by Mckenzie et al (2005a) periodic service review considered numbers of limitations, as limit geographical group was participating as not to interrupt clients. It was stated that majority of services that received formal guidelines was able to enumerate and lists down target behaviour. This is essential in allowing a suitable efficient analogy and customized intervention, whereas, monitoring and evaluating usefulness of the interventions. Researchers in these study points out that however there is a formal guideline used widely by the services or care providers it is still difficult to put into practice constantly and properly. Thus the researcher also critically analyse by mentioning reasons why it is not execute consistently, which one of the main reasons was support staff working without enough skills and training, as well as knowledge in working with client with challenging behaviour. The conclusion made was simply suggests that even an existence of a formal guideline is implemented it does not guarantee that they will be executed properly and constantly. That it is essential to develop a need for an innovative approach including organizational obligation, staff training and concerning the entire service group in a collaborative approach. Since in the beginning of this study, the researchers are finding ways and reasons why despite the wide implementation of a formal guideline, services were still failing to apply strategies in targeting difficult behaviour.
Hudson et al (2001) Signpost for building better behaviour discussion was sufficiently discussed providing the positive outcomes of the research and interpreting the results base on the tables of each program. Wherein the program aim is to help parents, carers in providing support for children with Intellectual disability and challenging behaviour. The Signpost is delivery of useful materials such as guidelines including videotape on how to implement strategies in dealing aggression and getting support by a telephone call and enable parents and carers to produce their own action plan specific to the children they dealt with. Although it a long research process was conducted, reports of parents and carers who able to produce their own action plans stated that they are less hassled by the children by the help of Signpost which is appropriately implemented. It was also stated that it was disappointing for the researchers that huge number of participants who are nominated in the evaluation and completed pre tests, did not carry on to completing post tests or go after assessment. Researchers in these study finds it significant to match up the standard cost of delivery of an essentially preventive program such as Signposts to the expenses related with interventions for individuals who previously developed stern behavioural challenges. And in conclusion the association of the current pre-test and post test differences from earlier study is improving considerably bigger than those in the control group in the earlier study. Furthermore, there was no recommendations included, which the author of this dissertation finds it essential in reading and applying into practice. This is essential and could help in looking for the reason that helps in conducting the study.
Introduction
For the final piece of my dissertation, relevant areas and issues will be identified, resulting from the literature reviews that were undertaken. To come up to a discussion of specific areas of interest of the author which applies to the place of work and people who will be reading it. The finding of better ways in managing and understanding learning disability and challenging behaviour, together with underlying issues of failing to acknowledge proper ways to deal with people in the spectrum, despite of numerous support and trainings. These will also help the author to trying to come up to find a preventive measure, making practical solutions and problem solving.
People with learning disability may demonstrate challenging behaviour in various reason and stimuli. It can be difficulties associated with severe communication and social interaction whereas make the individual to show anxiety, feeling of confusion and frustration. And for this reason, they have the difficulty to express their self and have no effective way to respond but instead showing aggression and difficult behaviour. Which by undertaking the literature review that the DoH (2001) explained that individuals with learning disability have deficit ability to comprehend complex information and carry out and or be trained into new skills. Therefore it is essential that carers must be good communicators, allowing them to be more responsive to clients needs and to engage them on therapeutic level. The author of this dissertation will once again introduce area of practice, role and reasons in conducting and finding relevant answers to her question. In addition, relate the different literature reviews to place of practice as to whether it is applicable and happening. The author of this dissertation is a student from The University of Winchester, taking a degree programme Bsc Professional Practice in Health and Social Care. And have been into practice placement as a support worker for people with moderate to severe learning disability and autism. The area of practice is located at North London in a community based residential home. As a support worker for people with learning disability, our main role and job description is to support them in every possible way from the basic such as helping in personal care and domestic maintenance. This includes following the companies written care plan for clients, familiarize with clients support plan and strategies in implementing daily activities. Apart from that, is giving medication, taking and recording of structured teaching plan, and strategies in dealing with challenging behaviour.
Whilst deliberating the topic for my dissertation, the author was trying to incorporate all the given literature review as to whether it is happening in the practice. If such reviews will be able to answer questions the author is looking up to purposely use in the area of practice. Upon thoroughly reading articles related to the topic the author find out that the current intervention in dealing with challenging behaviour for people with learning disability is based on behavioural principles and must be dealt with classified reason of the target behaviour and prepare them for functionally equal adaptive skills as mentioned by Ball et al (2004), Feldman et al (2004). The author could say that in the area of practice support worker and workforce is still finding the best way to understand and come across in implementing strategies that will be suitable in dealing with difficult behaviour. Therefore results from these reviews were conflicting in terms that however there is efficient application of ways to manage challenging behaviour, services was not able to constantly implement it because of carers’ lack of skills and knowledge and carers who does not have qualifications to support clients with learning disability and challenging behaviour. As a support worker it is our responsibility to put into practice whatever trainings and knowledge we can contribute in helping our clients in attending to their needs. Therefore the services were not setting standard as to hiring people to work with enough qualification as to dealing with learning disability. But on the contrary, services looking after for people with learning disability should not be blamed in hiring people without qualification as it will save service cost and it is difficult to hire people who are tough to handle and end up being beaten by the clients during aggression and difficult behaviour. However there is presence of strategies in managing the situation, as incidents and accidents can happen at any time during difficulty takes place.
As a support worker, based on experience the training and support was given to confidently apply strategies to deal with learning disability that shows aggression, still it is difficult to manage them. As to difficult behaviour varied into such intensity and duration of sudden occurrence hence might threaten the safety and welfare of individuals thus preventing them from engaging them to community activities. As McKenzie et al (2005a) said that use of conflicting and reactive strategies may in turn as a contributing factor to the elevation of challenging behaviour. But as a support worker for clients with learning disability, reactive strategy is unintentionally used to manage clients who show aggression and difficulty. For example if clients begins to get impatient for a certain activity and show aggression as to hurting itself and others, even strategies to calm them does not work then cancellation of the activity is done to give to the client the idea that aggression has its consequences. Which in my view could be a form of punishment for the client as punishment could take form of aversive stimuli or taking away of desired item or activity. Thus it focuses on consequences of what had happen after the behaviour. Hence, did not look unto what happened before the behaviour that had trigger to showing the difficult behaviour. This was mentioned in the article the author have read and included in her dissertation. As the result of the Periodic Service Review had stated that thought there is formal guidelines, services still fail to appropriately report the target behaviour.
Upon discussing the results of the articles and literature reviews and making a way in applying them into practice, the author will then once again discussed literature review results undergone in this dissertation to able to compare and can be apply to practice. From thoroughly reading the Periodic Service Review result by McKenzie et al (2005a) the writer can carefully compare its used and application to the area of practice by starting with the similarities of ways in managing challenging behaviour and comparisons to what area it fails. The article had brought me to realize and learn where practice should be improved. As it was mentioned in the article that however there is formal guidelines applied in the service, an enduring difficulty in constantly implement and efficiently used in managing clients, services were still cannot consistently apply it. Due to underlying reason such as staff lack of training and knowledge, thus less experience on how to manage challenging behaviour. It was also emphasize that formal guidelines will not certify if it is properly implemented and it is vital to develop increase innovative approach with the help of organizational obligation, staff training and collaborative approach. As a support worker in the area of my practice however there is support provided by the company in educating all their staff by conducting trainings, seminars and team meetings. Thus all support workers have attended and participated, still failed to correctly implement it to practice as evidenced by incident reports and increase in giving medication for settling the client. Based on observation the author could conclude that support workers fail to recognize the need to assess the reason before the client had showed difficult behaviour. Clients with learning disability as mentioned at the beginning of this dissertation as people who has disorder of one or more developmental which involves understanding and communication by Emerson (2001). Therefore it makes them less able to verbalize, speak and explain insights and or solving problems. And were changes will be difficult to introduce as people with learning disability conforms to sameness. Challenging behaviour could therefore be compared to an iceberg in the sea as what we only see is the visible part and not knowing that underneath the water is a part that is still connected.
Whereas Signpost for Building Better Behaviour by Hudson et al (2001) were most of the focus are into helping parents and carers of children to actively support and come up to their own action plan in dealing with challenging behaviour. This will help in teaching their children with learning disability to overcome difficult behaviour as parents will taught them to manage by the help of strategies in a guidebook before difficult behaviour come to a high level that requires intensive intervention by professional services. Hence, will help parents and carers to be less hassled and satisfied in managing their child. However this review was focus on managing children with learning difficulty and challenging behaviour the subject matter could be somehow applicable to the practice area of the writer. Thus can be helpful in applying in practice by trying to get to the core of the main reason why clients with learning disability shows aggression, and manage it before it will rise up to a level where need for intensive professional approach is needed. Moreover, this literature review on the writers view in connection to finding answer to her research topic, somehow had given a chance to compare strategies that can be applied to her practice as well as compare the difference and similarities. Wherein Signpost for building better behaviour uses professional guidebook, enclose videos, and equipment for assessment in helping parents and carers to manage children with intellectual difficulty and challenging behaviour. In connection to the authors practice area, upon dealing with clients with learning disabilities and challenging behaviour a series of different guidebook and videos was also used to be able to manage the clients. Of such guidebook which is more particular in showing the clients acceptable behaviours in the level of their understanding. In example were the social stories, daily care plan, and video tracking of structured teaching plan.
The possibilities of the results from the articles, as the author look unto it can be possibly applied in the practice, because based on experience as a support worker for clients with learning difficulties and challenging behaviour, where monitoring of staffs performance is evaluated and as to whether standard application of interventions is maintained. And assessing the need for updating the trainings to help staff refresh their knowledge in dealing their clients. Moreover, in the setting were the author is working, similar to the explanation made in the article where introducing of new innovative approach, organizational obligation and collaborative approach is essential as to seek help from a group of services hand in hand to appropriately implement proper management in dealing clients with learning disability. The British Psychological Society and The Royal College of Psychiatrists (2009) said that co-ordination between services, that in the occurrence of complex needs, it is excellent practice to seek on expertise from mental health experts, older peoples’ mental health, generic dementia, and services for learning disability. Thus, the company where the author is practicing, collaboration between different services is present in helping all support workers to have a constant guide in managing clients with learning disability. This also includes team meetings whenever there is a need for raising concerns that is connected to any difficulties the staffs have been dealing in the workplace. For example, during meetings staff is given the chance to speak out observation and experiences as to whether there is a need to change any interventions or rather update the strategies in the management of difficult behaviour. As a support worker the one who truly have the knowledge in dealing clients are those who works closely with the client.
For the next question that the author of this dissertation will find as to whether results can be applied and the difference could it make in the practice. The author would confidently say that it would be applicable at some point wherein, improving where the literature review results had failed. It is applicable at some point because based on working with clients with learning disability and dealing with challenging behaviour, as a support worker the experience I have gained and realize that while doing this research it made the author understand the necessity to pay attention to better improve the need of her clients. Wherein, applying all trainings that was given by the company and avoid disregarding such into practice and not to be conform how recent practice goes as to avoiding change. As results from the literature reviews that few reasons such as difficulty recognizing the target behaviour. For the authors view and knowledge about challenging behaviour, could therefore be triggered by a disorder in the receptive communication which leads to anxiety and confusion for clients with learning disability. Hence, make them find hard to understand what other people are saying and unable to understand what is happening around them. Thus, showing difficult behaviour could be a way of communicating for them as the most effective manner for them to get a response. Which on the other hand, people who give response could conclude as a form of aggression and make them execute reactive strategies without assessing the need to find what triggers the challenging behaviour. It was stated by British Institute of Learning Disabilities, undated, Jefferies (2009), that intensive contact such as giving massage and therapy may be beneficial for people with learning difficulty who find communication difficult.
The literature review results undertaken in this dissertation therefore help the author to further elaborate applicability and the difference it could make. As the author had mentioned that application of the results can be implemented into practice but with further improving to where it has failed. Therefore includes improving the practice by applying consistently gained skills and trainings, advance response in dealing difficult behaviour as knowing the things that could trigger the action, reviewing of clients record as to care plan, teaching sessions, and preparing activities. Moreover, updating knowledge and skills through trainings and supervisions, and participating giving ideas that could help in producing better ways in dealing with clients during team meetings. Since people with learning disability clients are dependable to their service provider, wherein, individualized planning is essential as Sanderson (2007) stated that individual focus set up forms a basis of government policy and the personalisation programme for Valuing People Now (DH 2009b), which enabling care plans to integrate appropriate individualised interventions and activities. The used appropriate individual planning is used in authors practice in dealing with the clients. As these will help in advance on how to execute daily routines, people with learning disability lives in conformity of routines and sameness hence, make it difficult to introduce new functional activities.
For example, based on the authors experience as a support worker, regarding the video tracking, where clients are being taught of some functional activities such as doing the laundry, making cup of tea, and cooking. Choices are being introduced to the client to find their preferences if the activity will be enjoyable for them or could trigger them to act to violence. If client is willing to do the activity staff to show a folder of pictures for the clients guide on what is going to happen next. Therefore, it will help the client to lessen confusion about the activity. Throughout the course of activity video recording is done, where all staff should follow the same procedures. The aim of video tracking is to see staffs performance and compare prompts that were used to the client. Is all staff follow the given prompts together with the pictures, thus allow conformity to the clients as similar prompts were used by all staff. Moreover, the activity will help client to gain independence in simple daily routines as the companies aim is to enabling people with learning disabilities to lead ordinary lives. In the course where clients are aggressive and show difficult behaviour it is safer to perform non-reactive and restraint-free interventions. As restraint may take many forms which includes physical, environmental, or chemical wherein, The British Institute of Learning Disabilities (BILD 2008) and the Care Quality Commission (CQC 2010) had provided guiding principles on seclusion and restraint and the human rights and dignity of people with learning disability. Whereas, improper physical intervention comprises assault or negligence that can lead to criminal prosecution. It was taught during training that given by the company where the author is practicing, that applying non-violent intervention can be applied in crisis prevention and creation of restraint free environments. There may be times when other strategies, such as continuing verbal intervention, removing dangerous objects, using personal safety techniques and calling for further assistance, would precede and possibly prevent any physical intervention.
Recommendations
Therefore at this point the author of this dissertation will look on the practices and considerations where practice can be further improved. Following a complete review of the literature relating to understanding and managing people with learning disability and challenging behaviour, the Author is able to conclude with recommendations for practice relevant to own area of practice.
Following where the literature review results undertaken on understanding and managing learning disability and challenging behaviour, where most staff had failed to recognized the need to evaluate what triggers the client and focuses on the course of action. Staff should be aware at all times on underlying cause of the actions. Applying all strategies provided by services, companies to where your practice is undertaking.
This recommendation was made with consideration to whether where is the writer or reader is practicing. As we all knew that different services and companies have their own written guidelines on how they dealt with clients with learning disability and difficult behaviour. But most of these services are similar on their aims as to provide quality care and safely provide interventions to help clients cope up difficulty.
Applying all learned skills during trainings, team meetings and protocols within practice area as constant as possible. Avoiding conformity as how things goes within the practice area, and must be open to new set of interventions being introduced. Especially if both staff and people with learning disability will benefit from it.
Some evidence in the literature reviews undertaken suggests that applying individual based intervention can be beneficial as to appropriately manage challenging behaviour where assessment to individual client is done to provide direct action specified to the level of needs and understanding of the client. By creating action plan where staff could used to own advantage to lessen anxiety and stress at the area of practice.
Support workers, carers and other organizational services should help each other in finding a better management of difficulty within the workplace by providing support where staff needed and monitoring the improvement and outcomes during regular team meetings and implementing new approaches which can be useful in the area.
Majority of the article in this dissertation had pointed out that the need for support workers to be fully equipped with knowledge and understanding in managing clients with difficulties includes openness to change. As staff should not conform into provided guidelines as it does not guarantee to be implemented consistently at all times. The development of new strategies and interventions with the help of other organization and collaborative approach will be essential in any area of practice.
Avoiding the use of a reactive approach or physical intervention as to restraint and seclusion, which will bring negative stress sometimes called distress to the client being restrained and or secluded.
Staff should remember that there are risks involved in any reactive and physical interventions. Where specific laws or policies may govern use of restraints, staff must check their organization’s policies and procedure for applicable rules.
The used of therapeutic rapport, or communication as response during the individual’s tension reduction is beneficial in attempting to talk to the person.
If the tension reduction occurs during the event of aggression, it is best to reassure client after assessing that staff are not going to harm them. Then these allow some time for the client to calm and regain rationality. As this form a verbal contract to client and allow them to make their own choices while staffs still maintain control, where should another violent outburst occur.
Conclusion
Understanding and Managing Learning Disability and Challenging Behaviour was indeed made the writer feel frustrated in trying to come up to a better way of presenting it in this dissertation. But through ongoing to the different literature review, critically analyzing evidence based results and finding the applicability to practice. The topic requires careful considerations where application of different interventions and strategies to consistently manage clients with difficulties, had made the writer to compare the review of literature undertaken to the area of practice. Based on the information gathered and researching related topics to my dissertation question, I was able to choose relevant literature reviews. This had created an impact to the authors chosen topic and find answer to her research question. The fact that all review of literature taken had given all process in implementing interventions and strategies to effectively manage challenging behaviour by means of Periodic Service Review and Signpost for building better behaviour which the author had both critique.
Upon conducting the whole process of this dissertation, the author had acknowledged that even in the event were services implement guidelines, action plans, reactive approaches, and other forms of interventions in managing and understanding learning disability and challenging behaviour, still it was not guaranteed that all service providers will appropriately and constantly implement it to the work area. Though enough training and support are provided in the service several staff still fail to properly target the reason behind client’s outburst and aggression. Hence the author had compared the reasoning into an iceberg in the sea. Wherein what we see is the only visible part and not the underlying part of it under the water. But then, the whole process of the dissertation had given the author benefits in undertaking this piece. As a support worker for people with learning disability and challenging behaviour, I still consider myself as a neophyte in this field of practice. Thus, it made me fortunate to be in line with this kind of practice, as it raised my curiosity to fully engage and finds way to help my clients in supporting them to overcome such difficulty. Which on the other hand, as the author of this dissertation, I have faced difficulties such as trying to critique review of literature where the author does not qualify expertise on that part of the dissertation. But somehow with the help of guides in producing the dissertation, I was able to make amends on it. Critiquing two studies has enabled the author to be certain that the knowledge acquired and recommendations for practice was made through evidence based.
The author believes that all research is a useful to any services that dealt with people in spectrum though not all research conducted were successful, critiquing allows the author to entirely examine and compare research in order to reveal the best method of practice. However, the need for further education regarding research process to properly understand results is needed as the author had faced difficulties in understanding research methodology. But through conducting this dissertation the author has not only gained extensive amount of knowledge of research processes as well as understanding and managing learning disability and challenging behaviour.
The author of this dissertation had gained knowledge which had brought positive impact upon further improving in the area of practice. And will therefore share the knowledge to her work colleagues to work as a team in implementing evidence based practice in supporting people with learning disabilities and properly execute appropriate and constant intervention in managing difficult behaviour. The author therefore will indicate that this research process had answered her topic question.
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