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National Collaborating Centre for Mental Health (UK). Challenging Behaviour and Learning Disabilities: Prevention and Interventions for People with Learning Disabilities Whose Behaviour Challenges. London: National Institute for Health and Care Excellence (UK); 2015 May. (NICE Guideline, No. 11.)

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Challenging Behaviour and Learning Disabilities: Prevention and Interventions for People with Learning Disabilities Whose Behaviour Challenges.

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10Environmental interventions

10.1. Introduction

The context in which behaviour that challenges occurs is an essential component in attempting to understand and hence change the frequency and/or intensity of the behaviour. In order to provide successful interventions it is necessary to understand the function of that behaviour for the person. The environment is one element of a functional analysis that needs to be considered when assessing the reason for that behaviour occurring. There may be features of a particular environment that contribute to the occurrence of particular behaviour. It is therefore possible, that by changing the environment (sometimes referred to as ‘ecological manipulation’), the likelihood of the behaviour occurring can be reduced.

Behaviour that challenges is known to increase in institutional settings or impoverished environments where there is a lack of engagement, poor social support, higher rates of restrictive practices and often higher reports of abusive practices (Department of Health, 2007). Poor parenting experiences can also increase the rate of behaviour that challenges, and may too be abusive. Over recent years there has been a shift from providing support to people with behaviour that challenges in institutional settings, to community-focused models of support that advocate person-centred planning and individualised care (Lowe et al., 2007a).

The environment is not just the physical space that a person occupies, but also the people, culture, social factors and opportunities that surround and influence the person. These factors are not mutually exclusive and will need to be considered as a whole when thinking about the right environment for a person. It has been recognised that the physical environment will need to be capable of meeting the person's needs and be tolerant of unintended use (Brand, 2010) and that the people within the environment will need to be provided with the tools to deliver person-centred care and support effectively.

McGill and colleagues (McGill et al., in press) use the terms ‘challenging’ and ‘capable’ environments. Challenging environments would include the practices often associated with institutional-style care and support or poor parenting practices. Capable environments are those that support a person effectively and provide the optimal setting to support positive interactions and opportunities. It is an holistic approach to align the multiple factors that form part of a person's environment including building design, an appropriate physical environment, consistency of support for communication, opportunities to engage in meaningful activities and develop independent skills, opportunities to make positive social interactions and to maintain relationships, provision of real choice, support to maintain good health, and a skilled staff team, supported through management and organisational values that promote personal preference and aspirations.

In order to ensure the right environmental fit for a person with a learning disability, it is necessary to understand their individual needs. Alongside understanding the function of their behaviour, this will often also include understanding their communication, sensory, health and support needs, preferences for activities, skill level, and engagement style. This will tend to require support from health and social care professionals to undertake assessments and provide a clear understanding of the person's needs. This work may be undertaken directly with the person with a learning disability and behaviour that challenges, or with their support networks to equip them to meet that person's needs.

There are approaches that seek to provide such understanding. Positive behavioural support (PBS) (Allen et al., 2005) seeks to better understand and so reduce the behaviour that challenges through use of a multi-element format to consider changing the environment, developing skills, providing focused support and developing reactive strategies. In this way environmental adaptations are not solely aimed at reducing the behaviour that challenges, but also at improving the person's quality of life (Mackenzie-Davies & Hardy, 2010). Person-centred active support (Mansell, 2007) seeks to provide an understanding of how to effectively engage people within their environments. Both models seek to enable people with a learning disability and behaviour that challenges to increase their confidence and self-esteem through exploration of their ‘capable’ environment, providing opportunity for developing interests and skills, and ultimately supporting mastery of the environment.

10.2. Review question: In people with a learning disability and behaviour that challenges, what are the benefits and potential harms associated with environmental changes aimed at reducing and managing behaviour that challenges?

The review protocol summary, including the review question and the eligibility criteria used for this section of the guideline, can be found in Table 73. A complete list of review questions and review protocols can be found in Appendix F; further information about the search strategy can be found in Appendix H.

Table 73. Clinical review protocol summary for the review of environmental interventions aimed at reducing and managing behaviour that challenges.

Table 73

Clinical review protocol summary for the review of environmental interventions aimed at reducing and managing behaviour that challenges.

10.2.1. Clinical evidence

The GDG considered the RCT evidence for this section of the guideline to be limited in terms of quality, directness and quantity. The range of included studies was therefore expanded to systematic reviews of non-randomised studies (see Table 74).

Table 74. Study information table for trials included in the meta-analysis of environmental interventions versus control.

Table 74

Study information table for trials included in the meta-analysis of environmental interventions versus control.

10.2.1.1. Sensory intervention versus any control

There were 3 RCTs (N = 137) that met the eligibility criteria for this review: Chan 2005 (Chan et al., 2005), Lundqvist 2009 (Lundqvist et al., 2009), Martin 1998 (Martin et al., 1998). Of the eligible studies, only 2 (N = 109) included sufficient data to be included in a meta-analysis (Chan 2005; Lundqvist 2009). One trial (Martin 1998; N = 27) included critical outcomes that could not be included in the meta-analysis because of the way the data had been reported; a brief narrative synthesis is therefore given to assess whether the findings support or refute the meta-analysis. An overview of the trials included in the meta-analysis can be found in Table 74. Further information about both included and excluded studies can be found in Appendix N and Appendix Q, respectively.

Summary of findings can be found in Table 75. The full GRADE evidence profiles and associated forest plots can be found in Appendices P and O.

Table 75. Summary of findings table for sensory interventions versus any control.

Table 75

Summary of findings table for sensory interventions versus any control.

No data were available for the critical outcomes of quality of life or service user and carer satisfaction.

10.2.1.2. Structured activity versus unstructured activity

There was 1 RCT (N = 26) that met the eligibility criteria for this review and provided sufficient data to be included in the evidence synthesis: Gencoz 1997 (Gencoz, 1997). An overview of the included trial can be found in Table 74. Further information about included and excluded studies can be found in Appendix N and Appendix Q, respectively.

Summary of findings can be found in Table 76. The full GRADE evidence profiles and associated forest plots can be found in Appendix P and O.

Table 76. Summary of findings table for structured versus unstructured activity.

Table 76

Summary of findings table for structured versus unstructured activity.

No data were available for the critical outcomes of adaptive functioning, quality of life or service user and carer satisfaction.

10.2.1.3. Motivating operations

For the purposes of this review, motivating operations are defined as those variables that alter both the effectiveness of reinforcement or punishment (the value-altering effect) and the frequency of operant response classes related to those consequences (the behaviour-altering effect).

No RCTs or systematic review of RCTs met eligibility criteria for this review. The search for additional systematic reviews identified only 1 that the GDG considered to be relevant: Simo-Pinatella 2013 (Simo-Pinatella et al., 2013). This systematic review included 31 single-n or small-n studies (N = 55): Ahearn 2003 (Ahearn, 2003), Buckley 2006 (Buckley & Newchok, 2006), Butler 2007 (Butler & Luiselli, 2007), Carey 2002 (Carey & Halle, 2002), Carter 2007 (Carter & Wheeler, 2007), Cautilli 2004 (Cautilli & Dziewolska, 2004), Chung 2010 (Chung & Cannella-Malone, 2010), Kuhn 2009 (Kuhn et al., 2009), Lang 2009 (Lang et al., 2009), Lang 2010 (Lang et al., 2010), Lanovaz 2009 (Lanovaz et al., 2009), LeBlanc 2001 (LeBlanc et al., 2001), Levin 2001 (Levin & Carr, 2001), Lomas 2010 (Lomas et al., 2010), McComas 2000 (McComas et al., 2000), McComas 2003 (McComas et al., 2003), McGinnis 2010 (McGinnis et al., 2010), O'Reilly 2000 (O'Reilly & Lancioni, 2000), O'Reilly 2006 (O'Reilly et al., 2006), O'Reilly 2007 (O'Reilly et al., 2007), O'Reilly 2008 (O'Reilly et al., 2008), O'Reilly 2009 (O'Reilly et al., 2009), Pace 2000 (Pace & Toyer, 2000), Piazza 2000 (Piazza et al., 2000), Rapp 2004 (Rapp, 2004), Rapp 2005 (Rapp, 2005), Reed 2005 (Reed et al., 2005), Ringdahl 2002 (Ringdahl et al., 2002), Roantree 2006 (Roantree & Kennedy, 2006), Thiele 2001 (Thiele et al., 2001) and Van Camp 2000 (Van Camp et al., 2000). Of the included studies, 15 were single-n studies and 16 were small-n studies. A summary of the included review can be found in Table 77.

Table 77. Study information table for the systematic review included in the review of antecedent modification.

Table 77

Study information table for the systematic review included in the review of antecedent modification.

All included studies were published in peer-reviewed journals between 2000 and 2010 and involved a process of functional assessment plus an intervention focused on the modification of a motivating operation. The mean age of included participants was 9 years (range 4-17 years) and 20% were females. All participants were diagnosed with a learning disability.

Fourteen of the included studies were conducted at the participants' school. Other settings in which studies were conducted included an inpatient unit or facility (k = 4), family home (k = 2), short-term residential facility (k = 2), an outpatient setting (k = 1), day service (k = 1), intensive day-treatment programme (k = 1), community-based group home (k = 1) and Centre Behaviour Analysis Clinic (k = 1).

Among the included participants, the most common behaviours were aggression (N = 22), stereotypic behaviour (N = 17), destructive behaviour (N = 17), self-injurious behaviour (N = 14) and tantrums (N = 11). Other behaviour that challenges included feeding problems (N = 5), disruptive behaviour (N = 2), pica (N = 1) and property destruction (N = 1). Behaviour that challenges was maintained by automatic reinforcement (N = 19), escape (N = 12), attention (N = 9) and tangible reinforcement (N = 6). Behaviour that challenges was maintained by multiple functions for 6 participants, and the behavioural function was not specified for 3 participants.

Motivating operations were classified as follows:

  • social context variables, involving attention from others and factors related to the characteristics of others
  • activity or nature of the task, involving instructional requests, presentation of work and the method of instruction
  • characteristics of the environment, involving factors related to objects or activities and environmental enrichment
  • personal context, involving physiological states.

Appendix N provides the study characteristics table for the review and methodology checklist; the review was judged to be of poor quality (that is, it met only 3 of the 5 criteria), and the quality of evidence for each outcome was graded as very low quality because of limitations inherent in SCSn studies (see Section 3.5.3) and the risk of bias associated with individual studies had not been assessed by Simo-Pinatella 2013. The authors did not include unpublished research, arguing that they are ‘usually incomplete and their accuracy may be difficult to assess’. However, they did supplement the electronic search by manually searching the reference lists of included studies and the table of content of journals that publish this type of research. In addition, a search was done of authors who commonly publish in this area.

Further information about both included and excluded studies can be found in Simo-Pinatella 2013.

Evidence from each participant was summarised by the review authors graphically and is reproduced in Table 78.

Table 78. Effect of different types of motivating operations on participants' behaviour that challenges in relation to its function (reproduced with permission of the copyright owner).

Table 78

Effect of different types of motivating operations on participants' behaviour that challenges in relation to its function (reproduced with permission of the copyright owner).

10.2.2. Economic evidence

No economic evidence on environmental changes for people with a learning disability aimed at reducing and managing behaviour that challenges was identified by the systematic search of the economic literature undertaken for this guideline. Details on the methods used for the systematic search of the economic literature are described in Chapter 3.

10.2.3. Clinical evidence statements

10.2.3.1. Sensory intervention versus any control

  • Very low-quality evidence from 3 separate studies (N = 20-89) of sensory interventions was either inconclusive or favoured the control across a range of relevant outcomes.

10.2.3.2. Structured activity versus unstructured activity

  • Very low-quality evidence from a single study (N = 26), showed structured activity was more effective than unstructured activity in reducing targeted behaviour that challenges at the end of treatment and at 6-week follow-up.

10.2.3.3. Motivating operations

  • Based on very low-quality evidence from a systematic review that included 31 single-n or small-n studies involving 55 participants, the following motivating operations had a clear effect on behaviour that challenges in the predicted direction:
    • the modification of instructional variables produced abolishing effects for escape-maintained behaviour
    • deprivation of attention had an establishing effect on attention-maintained behaviour
    • access to attention had an abolishing effect on attention-maintained behaviour
    • sleep disruption had an establishing effect on escape-maintained behaviour.
  • Changes in the level of attention did not appear to function as a motivating operation for escape-maintained behaviour
  • Evidence was inconclusive as to the effect of providing access to different types of tangible reinforcement on escape-maintained behaviour.

10.2.4. Economic evidence statements

No economic evidence on environmental changes for people with a learning disability aimed at reducing and managing behaviour that challenges is available.

10.3. Recommendations and link to evidence

Recommendations
38.

Do not offer sensory interventions (for example, Snoezelen rooms) before carrying out a functional assessment to establish the person's sensory profile. Bear in mind that the sensory profile may change.

39.

Consider developing and maintaining a structured plan of daytime activity (as part of the curriculum if the person is at school) that reflects the person's interests and capacity. Monitor the effects on behaviour that challenges and adjust the plan in discussion with the person and their family members or carers.

Relative values of different outcomesThe GDG agreed that a number of outcomes were critical to addressing this review question: targeted behaviour that challenges, rates of reactive interventions, quality of life, and service user and carer satisfaction.
Trade-off between clinical benefits and harmsReporting of harms was limited but in the case of sensory interventions (such as Snoezelen rooms) there was an indication that the provision of such interventions (which have been in widespread use) may not be beneficial and could be harmful to some people. Increases in structured daytime activity are likely to bring benefits with little, if any increase, in harms.
Trade-off between net health benefits and resource useNo economic evidence on environmental changes for people with a learning disability aimed at reducing and managing behaviour that challenges was identified. The provision of specific sensory interventions may result in modest additional costs. The development of structured daytime activities may also increase costs but the magnitude of such activities and the impact this may have on reduced resource use to manage behaviour that challenges are not known.
Quality of evidenceThe evidence was of very low quality, based on 4 small RCTs (N = 163) and a single review of SCSn studies.
Other considerationsThe GDG reviewed the evidence for 3 different kinds of environmental interventions: sensory interventions, structured daytime activity and motivating operations. The reviews did not find any evidence on the effectiveness of PBS.

The GDG carefully considered the evidence for sensory interventions and the possible harms and judged that they should not be used unless a functional analysis had clearly identified such interventions as likely to be of benefit. The very limited evidence for structured daytime activity was acknowledged by the GDG, but drawing on their expert knowledge of the impact of impoverished environments on the likelihood of increases in behaviour that challenges, they decided to recommend that plans for structured daytime activity should be considered.

The review of motivating operations suggested that the factors emerging from the review should inform the development of a range of interventions to address behaviour that challenges, but rather than develop a separate recommendation about them, the GDG felt that the evidence reviewed should be used to inform the development of recommendations on assessment and interventions covered in Chapters 8 and 11.
Copyright © The British Psychological Society & The Royal College of Psychiatrists, 2015.
Bookshelf ID: NBK355381

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