Positive behaviour support training: developing skills in community services

Depression is the most prevalent mental health problem among people with learning disabilities. The trial investigated the clinical effectiveness and cost-effectiveness of behavioural activation for depression experienced by people with mild to moderate learning disabilities. The intervention was compared with a guided self-help intervention. A multicentre, single-blind, randomised controlled trial, with follow-up at 4, 8 and 12 months post randomisation. There was a nested qualitative study. Participants were recruited from community learning disability teams and services and from Improving Access to Psychological Therapies services in Scotland, England and Wales. Participants were aged ≥ 18 years, with clinically significant depression, assessed using the Diagnostic Criteria for Psychiatric Disorders for use with Adults with Learning Disabilities. Participants had to be able to give informed consent and a supporter could accompany them to therapy. BeatIt was a manualised behavioural activation intervention, adapted for people with learning disabilities and depression. StepUp was an adapted guided self-help intervention. The primary outcome measure was the Glasgow Depression Scale for people with a Learning Disability (GDS-LD). Secondary outcomes included carer ratings of depressive symptoms and aggressiveness, self-reporting of anxiety symptoms, social support, activity and adaptive behaviour, relationships, quality of life (QoL) and life events, and resource and medication use. There were 161 participants randomised (BeatIt, n = 84; StepUp, n = 77). Participant retention was strong, with 141 completing the trial. Most completed therapy (BeatIt: 86%; StepUp: 82%). At baseline, 63% of BeatIt participants and 66% of StepUp participants were prescribed antidepressants. There was no statistically significant difference in GDS-LD scores between the StepUp (12.94 points) and BeatIt (11.91 points) groups at the 12-month primary outcome point. However, both groups improved during the trial. Other psychological and QoL outcomes followed a similar pattern. There were no treatment group differences, but there was improvement in both groups. There was no economic evidence suggesting that BeatIt may be more cost-effective than StepUp. However, treatment costs for both groups were approximately only 4-6.5% of the total support costs. Results of the qualitative research with participants, supporters and therapists were in concert with the quantitative findings. Both treatments were perceived as active interventions and were valued in terms of their structure, content and perceived impact. A significant limitation was the absence of a treatment-as-usual (TAU) comparison. Primary and secondary outcomes, economic data and qualitative results all clearly demonstrate that there was no evidence for BeatIt being more effective than StepUp. Comparisons against TAU are required to determine whether or not these interventions had any effect. Current Controlled Trials ISRCTN09753005. This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 53. See the NIHR Journals Library website for further project information.

Data suggest that approximately 50,000 adults with learning disabilities (LDs) in England and Wales are currently prescribed antipsychotic medication. Illness in this population is common, including significant rates of challenging behaviour and mental illness, but there is particular concern over the use of antipsychotics prescribed for reasons other than the treatment of psychosis. Control of challenging behaviour is the primary reason why such medications are prescribed despite the absence of good evidence for any therapeutic effect for this purpose. To assess the feasibility of recruitment and retention and to explore non-efficacy-based barriers to a blinded antipsychotic medication withdrawal programme for adults with LDs without psychosis compared with treatment as usual. A secondary objective was to compare trial arms regarding clinical outcomes. A two-arm individually randomised double-blind placebo-controlled drug reduction trial. Recruitment was through community learning disability teams (CLDTs) in south Wales and south-west England. Adults with LDs who are prescribed risperidone for treatment of challenging behaviour with no known current psychosis or previous recurrence of psychosis following prior drug reduction. A double-blind drug reduction programme leading to full withdrawal within 6 months. Treatment in the intervention group was gradually reduced over a 6-month period and then maintained at the same level for a further 3 months, still under blind conditions. In the control group, the baseline level of medication was maintained throughout the 9-month period. The blind was broken at 9 months, following final data collection. Feasibility outcomes were (1) the number and proportion of general practices/CLDTs that progressed from initial approach to recruitment of participants and (2) the number and proportion of recruited participants who progressed through the various stages of the study. Trial arms were also compared regarding clinical outcomes, the Modified Overt Aggression Scale, the Aberrant Behaviour Checklist, the Psychiatric Assessment Schedule for Adults with Developmental Disability checklist, the Antipsychotic Side-effect Checklist, the Dyskinesia Identification System Condensed User Scale, the Client Service Receipt Inventory, use of other interventions to manage challenging behaviour, use of as-required (pro re nata) medication and level of psychotropic medication use. Of the 22 participants randomised (intervention, n = 11; control, n = 11), 13 (59%) achieved progression through all four stages of reduction. Follow-up data at 6 and 9 months were obtained for 17 participants (intervention, n = 10; and control, n = 7; 77% of those randomised). There were no clinically important changes in participants' levels of aggression or challenging behaviour at the end of the study. There were no expedited safety reports. Four adverse events and one serious adverse event were reported during the trial. Recruitment was challenging, which was largely a result of difficulty in identifying appropriate persons to consent and carer concerns regarding re-emergence of challenging behaviour. Reduced recruitment meant that the full trial became an exploratory pilot study. The results indicate that drug reduction is possible and safe. However, concerns about taking part were probably exacerbated by limited availability of alternative (behavioural) interventions to manage behaviour; therefore, focused support and alternative interventions are required. The results of the qualitative study provide important insights into the experiences of people taking part in drug reduction studies that should influence future trial development. We recommend that further work focuses on support for practitioners, carers and patients in reducing antipsychotic medication. Current Controlled Trials ISRCTN38126962. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 47. See the NIHR Journals Library website for further project information.

This study was conducted on 24 childcare teachers who wanted to learn positive behavioral support in order to find out its effectiveness of positive behavioral support teacher training. The content composition of the positive behavior support program was carried out by consisting of a total of eight sessions based on previous studies. In addition, in order to confirm its effectiveness of positive behavioral support teacher training, the effectiveness was compared through the content validity verification process by borrowing positive behavioral support recognition and problem behavior guidance efficacy tools in previous studies. The results of the study are as follows. First, after the positive behavioral support training, childcare teachers The change in perception of positive behavioral support was statistically significant at the pre-post p<.001 level. Second, after the positive behavioral support training, the change in the efficacy of problem behavioral guidance by childcare teachers was significant at the pre-post p<.01 level. As such, it can be seen that positive behavioral support teacher training is very effective in improving childcare teachers’ awareness of positive behavioral support and problematic behavioral guidance. Finally, discussions and suggestions were made based on the results of this study. This study can contribute to the training policy to cultivate the expertise of childcare teachers who have difficulty in supporting problem behavior.

AimsSTOMP (stopping the over-medication of people with a learning disability, autism, or both) is a national project launched by NHS England in 2016. The objective is to curb the excessive use of psychotropic medication in individuals with a learning disability, autism, or both to manage behaviour that challenges. This means ensuring that medications are prescribed at the lowest effective dose for the shortest duration of time, and aiming to discontinue if appropriate.We aim to broaden the implementation of the STOMP initiative to a relatively new residential nursing home in Northern Ireland that is home to individuals with learning disabilities and complex care needs. The residents are discussed at monthly MDT meetings attended by psychiatry, positive behaviour support (PBS) practitioners, activities coordinators, and nursing home managers.MethodsThe inclusion criteria for STOMP are 1. Diagnosis of learning disability, autism, or both, 2. Currently taking psychotropic medication primarily for behaviour that challenges and 3. No diagnosis of severe and enduring mental illness. Five patients were eligible for STOMP.Outpatient letters and medication prescriptions from the time of admission were compared with the most recent outpatient letters and medication prescriptions.ResultsThe five residents were on a range of psychotropic medications including antipsychotics, antidepressants, benzodiazepines, and antihistamines. Following STOMP implementation there was a reduction in psychotropic medication for 80% of the residents.Patient 1: Reduction in antipsychotic from 75% BNF max daily dose to 40%.Patient 2: Previously on two antipsychotics with combined use of 75% BNF max daily dose – both medications now discontinued.Patient 3: Reduction in antipsychotic from 69% max daily BNF dose to 50%, PRN antihistamine discontinued.Patient 4: PRN antipsychotic discontinued from 15% max daily BNF dose, benzodiazepine use reduced by 5%.Patient 5: Antipsychotic use increased from 25% max daily BNF dose to 33%.ConclusionThere was a reduction in psychotropic medication in 80% of the residents. This is an encouraging finding and shows that the STOMP initiative can be expanded to include residential nursing homes. Despite relatively limited resources for STOMP implementation in our local service, we have shown that by keeping the STOMP ethos at the centre of our thinking during monthly MDT meetings involving nursing home management, PBS practitioners, psychiatry, and activities coordinators, we can make sustained reductions in psychotropic prescribing.

Aims This QIP aims to improve communication and information sharing between the community LD team, administration team, service providers and wider stakeholders, to ensure patient safety. The primary objective is to evaluate local initiatives to improve communication between MDT professionals and wider stakeholders. The secondary objective is to improve patient safety and staff satisfaction. Methods The COVID-19 pandemic created unprecedented communication challenges within the workforce and highlighted areas requiring review; this included information sharing among internal and external teams, collaborative teamworking, support in absence of senior clinical leadership and transition pathways from Child and Adolescent Mental Health Services to adult LD services. The QIP was initiated in March 2021. The discovery process included an initial consultation exploring practitioners’ experiences, areas for development and to share ideas for good practice. We used QI methodology, following ‘plan-do-study-action’ cycles, to analyse change. Change ideas included a single point of contact for internal and external queries, regular complex case management meetings, development of a referral process and clinical review for complex cases along with teaching sessions. Qualitative feedback from the team pre- and post-intervention, at baseline and regular follow-up intervals, in the form of monthly team meetings, emails, focus-groups and semi-structured interviews. Results A full thematic map was created after initial consultation; themes included communication improvement between teams and external agencies, timely support for complex case management, improving transition processes and development of robust clinical review processes. Qualitative feedback has been collated, analysed and final recommendations to be shared with the MDT professionals Conclusion Preliminary results have shown improvements in communication among the MDT, stakeholders, and external agencies. The consultation process highlighted that there is a substantial need for standardisation and consistency within communicative practices to promote enhanced care delivery and improved patient outcomes.

Positive Behavior Support has been shown to be effective in minimizing challenging behavior. Therefore training staff in Positive Behaviour Support would appear to be helpful in improving support to people with challenging behavior. The purpose of this review was to evaluate the research on the outcomes of Positive Behavior Support training. There are no other published reviews of Positive Behavior Support training outcomes. Searches were carried out using key words to identify studies which reported on Positive Behavior Support training. Following this, studies were evaluated against criteria for inclusion. 14 studies were identified by the review. Six studies focused on outcomes for staff. Four focused on outcomes for service users. Four studies reported outcomes for both staff and service users. Staff outcomes included changes in skills, confidence, knowledge, attributions and emotional responses. Service user outcomes demonstrated reduction in levels of challenging behaviour, but no evidence of change in quality of life was evident in the one study that evaluated this. Research demonstrates that Positive Behavior Support training has had a positive impact on knowledge, emotional responding, and attributions of staff. In addition, there is evidence of reductions in levels of challenging behaviour from service users. However, no evidence was found for Positive Behavior Support training having a positive impact on quality of life for service users.

The inspiring article by Daniel Wilson describes many of the issues central to working with men with learning disabilities who have gender identity needs, and highlights key areas on which learning disability services need to focus. I work as a clinical psychologist in a community learning disability team in East London, and have a particular interest in sexuality and gender. In this article, I will discuss some of the issues that resonate for me in thinking about how services have responded to the needs of people with gender needs, considering possible comparison with responses to people with needs relating to sexual diversity. I will then go on to discuss some of the personal and professional dilemmas that have arisen for me in my work with a man who cross‐dresses.

People with learning disabilities (LD) often experience challenges with activities of daily living (ADLs), which can impact independence and quality of life. Occupational therapy (OT) interventions that are personalised and engaging are needed to support functional skill development. This case report describes “Sing It, Do It”, a co-produced, music-based occupational therapy intervention to develop independence in bathing. The case concerns an adult with a moderate LD, autism, attention deficit hyperactivity disorder, and epilepsy receiving OT input from a community learning disability team. A familiar and preferred melody was selected by the client, and personalised lyrics were collaboratively developed to embed step-by-step bathing instructions within a song. The intervention aimed to support task initiation, sequencing, pace, and sustained attention through auditory and rhythmic cueing. A librarian-assisted literature review identified limited but emerging evidence for song-based interventions supporting functional skills in adults with LD, with most existing literature located within paediatric, educational, or music therapy contexts. Outcomes were evaluated using structured task analysis, repeated clinical observation, and caregiver report, reflecting real-world occupational therapy practice rather than formal research measurement. Following implementation, the client demonstrated increased initiation, reduced reliance on prompts, and improved independence in completing the bathing routine. This case contributes to the emerging evidence base for creative, occupation-focused interventions in adult learning disability services and highlights music-based approaches as a practical and underutilised tool within occupational therapy practice.

Purpose This paper aims to showcase the work of the Learning Disability Professional Senate (LDPS) to update their guidance on effective community learning disabilities health teams (CTLDs). Design/methodology/approach A working group from the LDPS was established and the document from 2015 was reviewed and updated to provide up-to-date guidance. The guidance was reviewed by all members of the LDPS and confirmed to be acceptable to all four nations of the UK. Findings A summary version of the updated guidance is included in this paper together with a link to the full guidance. Research limitations/implications The vision for community learning disability teams (CLDTs)/services relevant to the wider NHS agenda is to ensure they enable access to high-quality effective mainstream and specialist services that are equally accessible to all and designed to meet the needs and aspirations of people with learning disabilities, thereby reducing health inequalities and restrictive practices. Practical implications This guidance has been made available via the LDPS to commissioners and services across the UK. It is intended as a contemporary guide to best practice. Social implications The model promotes an integrated approach to health care. Originality/value To the best of the authors’ knowledge, this is the the first paper to summarise the revised LDPS guidance.

Government guidelines state that health services must measure outcomes for patients. However, there is only limited evidence on outcome measures for children with learning disabilities. This paper reports on a study designed to investigate the suitability and effectiveness of four outcome measures (Health of the Nation Outcome Scales for Children and Adolescents ‐ HoNOSCA, Children's Global Assessment Scale ‐ C‐GAS, Strengths and Difficulties Questionnaire ‐ SDQ, and Commission for Health Improvement Experience of Service questionnaire ‐ CHI) for a community team working with children with learning disabilities. The paper highlights the difficulties in capturing the impact of service intervention in a multidisciplinary community setting. The implications of the research for clinical practice are discussed.

Positive Behavior Support (PBS) is a framework that attempts to help reduce challenging behaviors displayed by service users however, little is known about the role of nurses and their perceptions of PBS. This qualitative study aimed to explore nurses’ perceptions and their roles in the PBS implementation in two forensic learning disabilities units in London. 19 nursing staff with experience implementing PBS were interviewed. Six themes were derived from thematic analysis, with findings in line with previous research. Recommendations highlighted introducing protected time for nursing staff to discuss PBS on the ward and providing more structured training and informed supervision.

Aims: To report the results of a week-long Alzheimer’s Disease (AD) pilot training and capacity building program for community caregivers in Lebanon. Study Design: Using mixed methods instruments, we collected participant demographics, measured participant understanding of baseline issues affecting the local aging population, the role of caregivers, and confidence in community supports. Knowledge gaps and challenges in AD care were identified. Place and Duration of Study: Six distinct areas of Lebanon including Tripoli, Keserwan/Jbeil, Beirut, Bekaa Valley, Sarafand and Nabatieh, from August 1-6, 2011. Methodology: Using mixed methods instruments, we measured participant understanding of baseline issues affecting the local aging population, the role of caregivers, and confidence in community supports. We also examined the usefulness of existing AD resources, identified characteristics of these front-line providers, and elicited details about educational and clinical needs in distinct religious and ethnic regions. Results: Of workshop participants, 94% were women, of whom 36% were 31 to 40 yearsof-age. Of the participants, 80% were social workers or nurses, and 65% were government employees. Participant motivation included a desire to mentor others (71%), Case Study Bazzi et al.; JSRR, Article no. JSRR.2014.009 186 improve communication with elders (69%), and better elderly care (61%). Participants said they learned most age-sensitivity training (74.4%), positive behavioral supports (60%), and strategies for difficult behaviors (55.6%). Incomplete evaluations and workshop fatigue negatively impacted data outcomes. Conclusion: Cross-cultural understanding of AD training in diverse settings is critical to developing appropriate training programs. Results underscore that community workers, the primary caregivers of AD patients in Lebanon, are sensitized to the disease, and through training, felt empowered to advance elders’ quality of care. Study challenges included group heterogeneous backgrounds, unfamiliarity with evaluation methods and the timing of the workshop, the summer heat and time of fasting.

Accessible summary Sensory integration is about how our brain receives and processes information so we can make sense of our everyday life. Behavioural interventions is a term used to describe how to teach people to increase useful behaviours or decrease behaviours that are challenging. Some people with severe learning disabilities can have behaviour that challenges and this can be difficult to manage. To manage behaviours that challenge restrictive interventions have been used such as people being given medication, or being held by others against their will. Instead of using these restrictive interventions we can use sensory strategies and a low stimulus environment which have been found to be successful in managing behaviours that challenge. AbstractIntroductionAdults with complex needs and severe learning disability present as a serious management problem within the community. Restrictive interventions are often used to manage adults with these issues, even though best practice recommends the use of positive behaviour support. Positive behaviour support involves functional analysis, but it does not specifically focus on sensory integration difficulties as a contributing factor to challenging behaviour.MethodsA systematic search of the literature was completed using a range of electronic databases, an electronic search, hand search and review of reference lists. Seven relevant studies were identified. These studies were critically appraised and analysed. However, the extent of research was limited and the procedural quality variable, some distinct themes, arose.ResultsOut of the seven intervention studies included in this review, two studies used sensory integration therapy, three employed multi‐element behavioural intervention, one utilised environmental stimulation within a multifactor behavioural intervention approach and one used sensory strategies within a structured behavioural intervention programme. The participants across the final seven papers reviewed consisted mainly of males with a high incidence of participants presenting with ASD. A range of assessment tools and outcome measures were used.ConclusionsThe use of restrictive intervention is still an issue in practice. Nearly all the studies reviewed stressed the issue of placing individuals with severe challenging behaviour in the community. Behavioural studies have successfully utilised sensory integration strategies within a structured behavioural format to manage challenging behaviour in a community setting for adults with a learning disability.

This article is a reflective piece written by the Intensive Positive Behaviour Support Service (iPBS) in South Wales. The iPBS team works with children and young people with learning disabilities and/or autism spectrum conditions, that communicate their unmet needs in ways that may challenge and are at risk of their support networks breaking down. The team works within the Positive Behaviour Support Framework and is shaped by attachment and trauma-informed research and practice. The main aims of the service are to understand unmet needs and to improve quality of life.The iPBS team completed a 1-hour reflection considering ‘hear me, don’t blame me’ and what this means to them, their roles and the service as a whole. Three key overarching themes were identified using thematic analysis: service structure, skills, and approach. The team hopes that the themes identified through this exercise will influence future iPBS processes and service delivery. The reflections explored in this article may also be beneficial for parents/carers and professionals working with a united aim of meeting the needs of children and young people presenting with behaviours of concern; beyond words. Clinical implications of the reflective piece are discussed and recommendations for other services to have their own reflections are provided.

The Learning Disability Screening Questionnaire (LDSQ) has been shown to have high sensitivity and specificity to identify those who are likely to meet intellectual disability diagnostic criteria (McKenzie, et al. ). However, there is no independent research to date to support these findings. An archival research design was used, utilizing data from diagnostic tools including the LDSQ, Wechsler Adult Intelligence assessments and Adaptive Behavior Assessment System Second Edition (ABAS-II) scores. Sensitivity and specificity values derived here were lower than those reported by (McKenzie, et al. ). Only IQ, not adaptive/social functioning, was found to be an accurate predictor of the LDSQ score. Results indicate limited validity in using(McKenzie, et al. ) proposed cut-off scores. The authors have expressed caution around using the LDSQ in isolation to identify those with an intellectual disability.