Andy McDonnell, PhD,

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A practical guide to low arousal approaches.

• Andy McDonnell, PhD,
• Director, Studio3 Training Systems,
• WWW.studio3.org

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Background

• Studio3 was founded in 1991 in the UK.
• The main aim was to develop evidenced based
  training in crisis management.
• The philosophy was to develop a non aversive
  framework to crisis management.
• This would be applied to the development of
  physical interventions.

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Non aversive approaches

• Early behavioural interventions concentrated on
  the consequences of behaviour.
• The use of punishing consequences to suppress
  behaviour has been extremely controversial.
• In many ways we attempt to control what we fear.
• In the last two decades there has been an
  increasing emphasis on intervening before a
  challenging behaviour occurs.
• Many of these approaches can be labelled as
  positive behavioural supports.

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Positive behavioural supports

• Carr et al, 1999A major review of 216 articles
  which included positive behaviour supports from
  36 journals published between 1985 and 1996 (Carr
  et al. 1999). 109 studies were included and 107
  were excluded from the review. (23 for absence of
  data, 28 inadequate design, 12 group designs, 33
  used pooled data, 31 studies contained
  insufficient baseline and seven studies reported
  insufficient intervention data).

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Low arousal approaches

• A key component of these approaches to behaviour
  management is REFLECTIVE PRACTICE.
• A carer may often be making a situation worse
  accidentally

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What makes you angry? How do you express your
anger? How do you cope? How do you De-stress?
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Definition

• " attempts to alter staff behaviour by avoiding
  confrontational situations and seeking the least
  line of resistance."
• (McDonnell, Reeves, Johnson Lane, 1998, p164)

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Low Arousal

• A non-confrontational way of managing challenging
  behaviour
• A philosophy of care which is based on valuing
  people
• An approach that specifically attempts to avoid
  aversive interventions
• An approach that requires staff to focus on their
  own responses and behaviour and not just locate
  the problem in the person with the label
• A collection of strategies that are designed to
  rapidly reduce aggression

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Low Arousal
Theoretical Assumptions

• ASSUMPTION ONE
• Most people who are challenging are usually
  extremely aroused at the time. We should
  therefore avoid doing anything that will arouse a
  person who is already upset.
• ASSUMPTION TWO
• A large proportion of challenging behaviours are
  usually preceded by demands and requests,
  therefore reducing these should help to reduce
  the frequency and perhaps the intensity of the
  incidents.
• ASSUMPTION THREE
• Most communication is predominantly non-verbal,
  therefore we should be aware of the signals we
  communicate to people who are upset.

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Key Assumptions

• Focus on the behaviour of caregivers. This
  includes reflective practices. was it my fault?
  or Did I make that situation worse?
• Trauma informed behaviour management. In essence
  we do not re-traumatise traumatised people.

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Symptoms of physiological arousal

• In anxiety disorders arousal is increased in
  response to a perceived threat.
• Rapid beating heart.
• Sweaty hands and other forms of perspiration.
• Pupils may increase in size.
• Panic reactions (including escape from
  situations).

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Non verbal behaviours

• Eye contact Should be avoided when a person is
  angry.
• Touch Keep this to a minimum.
• Interpersonal space We are much more aware of
  the space around us when we are angry or aroused.
• Postures Threatening postures need to be avoided.

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Non verbal behaviours

• Language language needs to be clear and simple,
  avoid ritualistic debates.
• Avoid key trigger phrases such as calm down
• Do attempt to appear calm and give off a minimal
  amount of energy.

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Anatomy of an Incident
CRISIS
Arousal Level
Triggering Phase
Normal range
Time
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Behaviour is about perceptions
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Behaviour

• THOUGHTS
• FEELINGS
• BEHAVIOUR

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The banana skin example

• I want you to imagine that you are walking down a
  high street.
• You slip and fall over on a BANANA SKIN.
• You are not hurt.
• What would you be thinking?
• What would you be feeling?
• How would you behave?

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Banana skin

• Now imagine you fall over again.
• You are not hurt.
• There are lots of people around looking at you.
• What would you be thinking?
• What would you be feeling?
• How would you behave?

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Banana Skins

• You fall over again.
• A teenager with his mouth full of banana laughs
  at you?
• WELL????????????

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A BAD EXAMPLE
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Video exercise 1

• What is the person doing to make the situation
  worse?

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A Better Example
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Video exercise 2

• What do you think is happening in this situation?

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Exercise 3
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Video exercise 2

• How would you feel in this situation?

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Video exercise 3

• What is different about the next clip??

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Video exercise 3
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Sensory difficulties in ASD

• Increasing interest in this area.
• some autistic individuals cannot tolerate food
  of some particular taste, smell, texture and
  appearance (certain colours for example) or even
  the sound it produces when they chew it
  (Bogdashina, 2003, p63).
• Sensory difficulties are vital to understand if
  staff are to develop behaviour management
  strategies.

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Outer and inner senses (Shore 2004)
sight
Vestibular (Inner ear) Balance Proprioceptive (M
uscles and joints) Sense of body in space
touch
hearing
smell
taste
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Sensory difficulties

• Processing using one modality.
• Inconsistency in visual perception.
• Sensory agnosia (difficulties interpreting a
  sense).
• Delayed processing.
• Sensory overload Remember this can be a painful
  physical experience for some people.

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IntroductionSome behaviours in ASD linked to
sensory issues 1

• Outbursts following crowded environments or group
  conversations
• Bright lights uncomfortable/ dimness preferred
• Disorientated in environments rich with visual
  stimulation
• Plays with lights and shiny stuff
• Repetitive humming or loud outbursts
• Discomforted by loud or low frequency noise
• Delayed response or over reaction to sudden
  noises
• Over reaction to smells especially those
  
  no one else can detect

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IntroductionSome behaviours in ASD linked to
sensory issues 2

• Preference or insistence on (same) bland food
• Fascination with how people smell
• Aversion to perfumes and air fresheners
• Strong preference for gentle or firm touch or
  pressure
• Unusually high or low response to pain
• Unusually high or low response to
  temperature-highly sensitive
• Unhappy in new clothes, sensitive to how clothes/
  how bedding feels

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To be lightly touched made my nervous system
whimperGunilla Gerland
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An Older Adult

• Peter was a 79 year old man. He lived on his own
  in a two bedroom house on the edge of a small
  Northern town in the UK. His wife, Edith, passed
  away 12 years ago. Peter had a variety of manual
  jobs in the past including 12 years as a miner.

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Older Adults

• Peter had a team of staff who provided practical
  support in his home on a regular basis. The local
  agency found it difficult to get staff to work
  with as he was abusive and threatening,
  especially to Black workers. Racists insults were
  commonplace. Several staff in the support service
  refused to work with him until his racist
  language was dealt with.

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Older Adults

• Last month he was visited by two social workers
  and the director of the local staff support
  agency to discuss his racist comments. They had
  decided to visit as a group as they felt that
  this would be safer. He was told by the agency
  representative that all support would be
  withdrawn if his racist behaviour persisted. The
  main consequence of this withdrawal of support
  would be that he would be likely to be placed in
  a local authority care home. Upon hearing this
  Peter became verbally abusive and threatening and
  he threw a mug of coffee which hit the
  representative of the local support agency on her
  head resulting in stitches.

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Older Adults

• Staff who worked directly with Peter attended a
  two day training within two weeks of the
  referral. This course consisted of legal aspects
  of care, debriefing, understanding the causes of
  challenging behaviour with specific emphasis on
  dementia.

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A cognitive example

• Case example A child with ADHD presented with
  both physically aggressive behaviours and verbal
  threats on a daily basis. After an initial
  assessment it was discovered that staff
  attributed causes to stable dispositional
  characteristics of the person. The negative
  attributions were summarised by one member of
  staff 'The verbal threats are methods
  (disposition) he has always (stable) used to
  control others. He will never change (stable).
  That's the way he always behaves when he does not
  get what he wants (controllability)".

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A cognitive example

• It was found on analysis that the person was
  sensitive to noise, heat and mood swings which
  were not always under his control. He also had
  problems controlling his anger. A rationale was
  presented to his carers which argued that the
  person was rarely in control of his behaviours.
  At one year follow up it was found that the
  frequency of behaviours had not radically
  altered, however, the majority of staff felt that
  these same behaviours were less problematic as
  they understood that there were many times where
  the person 'just loses control'.

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Food

• Case Example For the last year a young woman
  with autism and challenging behaviours has been
  eating large amounts of food in her residential
  home. In this time she has gained nearly three
  stone in weight and her carers are concerned that
  it is affecting her health. She has demonstrated
  a capacity to understand the implications of not
  dieting on her health. She was placed on a low
  fat diet by her consultant psychiatrist and her
  assaults on staff became very frequent.

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Food

• After seeking advice from an advocate she was
  taken off this diet and allowed to eat foods of
  her choice. Although the staff accept that it is
  her right to eat food of her choice they remain
  worried about her potential health related
  problems'.

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Case study

• John was a 35 year old man with mental health
  problems and learning disabilities.
• Admitted to a locked ward after incidents of
  physical aggression.
• He was described as argumentative.
• One member of staff stated I have no time for
  him

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Reactive plan

• Staff received training in Studio3 methods.
• Persistent areas of confrontation analysed.
• Staff practiced avoiding arguments.
• Staff encouraged to monitor each others
  behaviour.
• Demands reduced.

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Low arousal case study McDonnell et al 1998.
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An adolescent

• Jamie was 13 years old and suffered from years of
  neglect and abuse.
• He would regularly abscond from his residential
  care home.
• Staff would use sanctions and natural
  consequences to stop the behaviour.
• These approaches did not reduce his absconding.

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Jamie (Contd)

• Staff decided to tell him that he had to take
  control, of his behaviour.
• They were concerned about him.
• If he wanted to leave then he could tell staff
  where he was going.
• They said that they would make sure that his
  mobile worked.
• Jamie thought the staff were well weird.

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Behaviour change or behaviour support?

• Low arousal approaches involve looking for the
  least intrusive methods of avoiding
  confrontation.
• I believe that our job is to support people
  rather than to change them.
• People are different not deviant.
• IF BEHAVIOUR NEEDS TO CHANGE ITS OURS NOT THEIRS
  THAT NEEDS CHANGING!

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Debriefing Rules

• Confidential
• Someone you feel confident with
• Not about what went wrong it is about resolving
  feelings
• What people say should be valued and respected

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Physical Interventions

• Physical interventions are defined as any
  methods of responding to challenging behaviour
  which involves some degree of direct physical
  force to limit or restrict movement of mobility
  (Harris et al. 2000, p2).

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Rates of usage

• Emerson et al. (2000) in a survey of 500 people
  in the United Kingdom and Ireland labeled with
  challenging behaviour reported 23 of the sample
  had experienced physical restraint.
• A survey of 625 service users in Canada 12.3 had
  experienced physical restraint.(Feldman et al,
  2004)

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Physical Interventions

• There are many training courses which teach
  physical skills borrowed from the martial arts.
• We wanted to develop physical strategies
  specifically for the most common situation
  encountered in autism services.
• We wanted to avoid dehumanising and dangerous
  methods.

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Developing Alternative Physical interventions

• Safety.
• Effectiveness.
• Social validity.
• The avoidance of pain.
• The avoidance of dehumanising postures.
• Teach as few physical interventions as possible.
• Accept that there are not training solutions for
  every problem.

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Prone holds
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Avoiding PI
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Avoid Physical interventions
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The Millfields Charter

• www.millfieldscharter.com

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Training in PI Less is more

• Moving from rhetoric to reality?
• The following guidance I believe should be viewed
  as aspirational in nature.
• Train staff in minimal physical interventions
  only in situations.
• The more staff you train in a service the greater
  the likelihood of usage.

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Actively monitor procedures

• Active monitoring requires that staff review
  multiple incidents of PI.
• Service managers need to be actively involved.
• Practical questions should be resolved in short
  restraint reduction meetings.
• Set targets for reduction.

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Questions?

• What could prevent this incident from happening
  next week?
• Does the programme need altering?
• Are the staff confident to manage the persons
  behaviour?
• What diversionary strategies are being used?

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Create a service culture of PI reduction

• High quality services where service users have
  choice and a range of activities/ life
  experiences often have lower PI usage.
• In any services the attitudes of managers to
  physical interventions is of paramount
  importance.
• A positive culture starts from the premise that
  there are always alternatives to physical
  interventions.
• Robust and independent monitoring mechanisms are
  a necessity.