A complex systems perspective on chronic aggression and self-injury: case study of a woman with mild intellectual disability and borderline personality disorder.

BACKGROUND: Challenging behaviors like aggression and self-injury are dangerous for clients and staff in residential care. These behaviors are not well understood and therefore often labeled as "complex". Yet it remains vague what this supposed complexity entails at the individual level. This case-study used a three-step mixed-methods analytical strategy, inspired by complex systems theory. First, we construed a holistic summary of relevant factors in her daily life. Second, we described her challenging behavioral trajectory by identifying stable phases. Third, instability and extraordinary events in her environment were evaluated as potential change-inducing mechanisms between different phases. CASE PRESENTATION: A woman, living at a residential facility, diagnosed with mild intellectual disability and borderline personality disorder, who shows a chronic pattern of aggressive and self-injurious incidents. She used ecological momentary assessments to self-rate challenging behaviors daily for 560 days. CONCLUSIONS: A qualitative summary of caretaker records revealed many internal and environmental factors relevant to her daily life. Her clinician narrowed these down to 11 staff hypothesized risk- and protective factors, such as reliving trauma, experiencing pain, receiving medical care or compliments. Coercive measures increased the chance of challenging behavior the day after and psychological therapy sessions decreased the chance of self-injury the day after. The majority of contemporaneous and lagged associations between these 11 factors and self-reported challenging behaviors were non-significant, indicating that challenging behaviors are not governed by mono-causal if-then relations, speaking to its complex nature. Despite this complexity there were patterns in the temporal ordering of incidents. Aggression and self-injury occurred on respectively 13% and 50% of the 560 days. On this timeline 11 distinct stable phases were identified that alternated between four unique states: high levels of aggression and self-injury, average aggression and self-injury, low aggression and self-injury, and low aggression with high self-injury. Eight out of ten transitions between phases were triggered by extraordinary events in her environment, or preceded by increased fluctuations in her self-ratings, or a combination of these two. Desirable patterns emerged more often and were less easily malleable, indicating that when she experiences bad times, keeping in mind that better times lie ahead is hopeful and realistic.

Effectiveness of instruction and video feedback on staff's trainer behavior during one-to-one training with children with severe intellectual disabilities.

In this study, the effectiveness of instruction and video feedback on response prompting and trainer behavior of direct-care staff during one-to-one training with five children with severe intellectual disability was assessed. During instruction, written information and verbal instruction were given concerning correct and incorrect trainer behavior and response prompting. Video feedback consisted of (a) interrupting a video presentation if an error occurred, (b) providing positive feedback, and (c) prompting the trainer to avoid errors or omissions. The results showed that instruction resulted in an improvement (though not significantly) in correct trainer behavior while video feedback was significantly effective in improving correct trainer behavior. Results were maintained at a 5-week follow-up.

Self-management and supervisory feedback improves trainer implementation of communication rehabilitation programmes.

OBJECTIVE: This study investigated the differential effects of self-management and supervisory feedback on the acquisition and maintenance of accurate use of response prompts by five trainers who provided communication training to individuals with severe intellectual disability. METHODS: A counterbalanced design was used. For three trainers the self-management condition was first in effect followed by the supervisory feedback condition. For the two other trainers this order was reversed. RESULTS: Results revealed that for three trainers there was a statistically significant difference between the two conditions, favouring supervisory feedback. For the other two trainers, self-management and supervisory feedback were equally effective in establishing accurate use of response prompts. Acceptability ratings from trainers suggest a preference for self-management over supervisory feedback. CONCLUSION: For three out of five trainers supervisory feedback was more effective in improving implementation of the communication intervention (i.e. response prompting) than self-management.

Professional development improves staff's implementation of rehabilitation programmes for children with severe-to-profound intellectual disability.

OBJECTIVE: To evaluate the effectiveness of supervisory feedback and self-management on the acquisition and generalization of correct implementation of rehabilitation training programmes implemented by direct care staff. DESIGN: A non-concurrent multiple baseline design across three trainer-trainee dyads was used. METHODS: Three staff members were trained in how to implement one-to-one teaching programmes with four children with profound-to-severe intellectual disability. Staff received feedback and were taught to self-manage their (in)correct trainer behaviour. RESULTS: Supervisory feedback and self-management increased the mean percentage correct entry behaviour and reinforcement during training. Trainer's use of entry behaviour and reinforcement generalized across settings and trainees. As levels of response prompting for three trainers were already high during baseline, no firm statements could be made concerning its acquisition and generalization. CONCLUSION: Staff can improve the accuracy of training as a result of feedback and/or self-management procedures in the rehabilitation of children with severe disabilities.

Instruction and video feedback to improve staff's trainer behaviour and response prompting during one-to-one training with young children with severe intellectual disability.

We investigated the effectiveness of instruction and video feedback on correct trainer behaviour and the use of prompt sequences of 10 direct-care staff during one-to-one training with 10 young children with severe intellectual disability. Following baseline, trainers received instruction (written and verbal) concerning (in)correct trainer behaviour and response prompting. Then, video feedback was implemented and consisted of (a) interrupting a video presentation if an error occurred, (b) providing positive feedback, and (c) prompting the trainer to avoid errors or omissions. Data were collected in a non-concurrent multiple baseline design. The results showed that instruction and video feedback were highly effective in improving correct trainer behaviour. During baseline, trainers were inconsistent in their use of prompt sequences (21 correct prompt sequences were used as well as 17 incorrect prompt sequences). The intervention was effective in decreasing the number of incorrect prompt sequences. The trainers rated instruction and video feedback as an acceptable and effective intervention.

Effectiveness of instruction and video feedback on staff's use of prompts and children's adaptive responses during one-to-one training in children with severe to profound intellectual disability.

Although relatively many studies have addressed staff training and its effect on trainer behavior, the effects of staff training on trainee's adaptive behaviors have seldom been examined. We therefore assessed effectiveness of staff training, consisting of instruction and video feedback, on (a) staff's response prompting, and (b) staff's trainer behavior during one-to-one training with four direct-care staff who acted as trainers. Next to this, we evaluated the effects of staff training on adaptive skills in four children with severe to profound intellectual disability. A non-concurrent multiple baseline design across staff-trainee dyads was used. Intervention resulted in an immediate and substantial increase in percentage correct response prompting and percentage correct trainer behavior by staff. The intervention was also effective in increasing percentage of trainee's correct responses. Staff rated instruction and video feedback as effective and acceptable. Results are discussed in terms of their implications for future research.