Behaviours of Concern

Restrictive Practices Update in Light of NDIA Commission Developments

The NDIS Commission launched 1 July 2018 with new standards for behaviour support. In NSW we have entered into a joint agreement that fits our standards within the umbrella determined by the Commission. This means a few changes to NSW Policy and Practice. To read more and learn about the changes, click on the links.

These vital and important developments are not without their growth pains. However we need to keep a view to the big picture – that emerging requirements will aim towards eventually strengthening the review of restrictive practices. This is important for individual’s rights to adequate treatment under legal, ethical, and professional standards. The hope is that legal, ethical, and professional standards will be upheld among some of Australia’s most vulnerable population.

20171224_101139 — Australian standards for Restrictive Practices is vital towards protection of the human rights of people with disabilities.

On the ground people who come forward for behaviour support reviews are somewhat surprised by the administrative burdens of 1. setting up a service generally under the NDIS and 2. processing issues around cases with restrictive practices.

After 1 July 2018 in many cases existing funding allocations may not be adequate to address the complexities of NDIS Commission requirements. This means that participants may face NDIS Plan reviews that can often take a great deal of time, leading to delays in situations where risks tend to be high.

Lengthy NDIS template forms for behaviour support and equally extensive NSW authorisation processes go in tandem with behaviour support reviews by practitioners. It appears that NDIS requirements may easily double if not triple the time it once took to provide clinical reviews, in large part due to compliance measures for data collection by the Commission.

While the new requirements may lead towards greater compliance and standardisation of services across the sector, there are always inherent risks when a government department takes oversight of clinical and professional roles. Whether discussing the historical track record in the UK or in other countries, in relation to Australian core disability service standards we are next in line for major adjustments and growth pains across the disability sector.

Implementing providers such as those managing day programs or home based supports are required to undertake NSW state level restrictive practice authorisation reviews. This process requests a great deal of information and forms, and in some cases appears to double up what is required by the Commission. The time it takes to process information appears so far to be without funding allocated for these complex mandatory requirements. It is unclear how vulnerable people with disabilities will fair in the midst of these contradictory set of circumstances. But like all things NDIS, there are positives and negatives as the Scheme rolls out across the country.

In the bigger picture, the NDIS Commission is charged with a large and important undertaking, and as things roll along the goals of monitoring and safeguarding will invariably be shared with the states. The proposed role of NSW for example is quite vital for the purposes of reviewing restrictive practices, how they are managed, and in what ways they can be reduced or eliminated over time. External senior clinical review appears to part of the NSW proposed authorisation model, which makes absolute sense. The state is taking on the burden of cost for maintaining a list of qualified external reviewers who will sit on review panels alongside the organisations presenting the restrictive practices review request.

Even though the NDIS has been trundling along for a few years already, and the safety net that once existed for people with disabilities has vastly expanded to include many more people within funded supports, the NDIS Commission role for people with more profound disabilities and behaviours of concern who require restrictive practices review is extremely necessary and entirely reasonable. How they go about this vital task is another matter, which Australians may not entirely comprehend for some time to come.

At the end of the day, it is important to see one thing clearly. The NDIS Commission and the NSW Restrictive Practices Authorisation under Family and Community Services are undertaking one of the most core and vital responsibilities of the disability services sector. In many ways this should have been the first undertaking of the NDIS. But we welcome the leadership of the Commission and the NSW FACS and we look forward to the ways that disability standards in Australia will grow and evolve from this point onwards.

September 21, 2018

Specialist Behaviour Support

NDIA Commission Lauch 1 July 2018

The new financial year brings new government oversight of behaviour support. In NSW where we are based, the state system has now fully transitioned (more or less) to the new national system.

This means that disability service providers will face new regulations and standards for behaviour support practice. The NDIA Commission’s new website just launched provides the detailed legislative instruments that will guide and direct upcoming changes and management of behaviour support as well as other functions of governance across the sector.

Disability service providers until now have been managing within a transitional environment. For the past five or so years, this context includes the disbanding of state based agencies like the Department of Ageing Disability and Homecare. In the absence of state based leadership, disability non-gov organisations have been responsible to govern behaviour support policy and practice still under the state established guidelines. Effectively, many organisations have struggled in the wake of NDIS transitions where due to funding shortages they may have let go of staff, not had resources to hire behaviour support practitioners for review of cases, and not been able to maintain independent oversight of clinical services through restrictive practices analysis, authorisation, and review.

In all likelihood, most multi-service option organisations will be doing the catch up, with many people waiting on clinical reviews, and many more individuals carrying old and outdated behaviour support plans. These plans, and the ideally holistic and generative clinical oversight that they represent, are the foundation of positive person centred behaviour support practice.

Alongside, NSW has a history of major investments in capacity building across the disability sector. For example, for over a decade past, Stronger Together reforms established behaviour support practices across the state and offered skills training to NGOs across the sector. Also parallel, the current reality on the ground appears to suggest that the disability NGO sector cannot sustain behaviour support practices without significant independent input by clinicians and specialists. Such expertise tends to be rare, particularly in rural Australia.

The reforms ahead will be interesting to say the least. NDIA Commission led reforms will need to provide vital sector wide leadership as well as provide a conduit for seasoned clinical advice. In saying this, we acknowledge that behaviour support policy and practice are a backbone to the disability services sector – and have held an historical and key society wide leadership role in the spread of positive behaviour support practices and standards.

Where individuals have behaviours of concern, these often touch on every other aspect of life, lifestyle, health, relationships, and community participation. As a field that represents fundamental human rights to dignity and fair treatment, positive behaviour support standards represent key international and national guidelines. The NDIS and now its Commission has a key role in Australia to forward these standards for the wellbeing of Australians.

July 1, 2018

Inverell Community Clinic

Ability Therapy Specialists begins this Monday providing a fortnightly clinic in Inverell focused on participants of the National Disability Insurance Scheme. We are hosted by Inverell’s own Individual Ability Supports (IAS). We also have participants coming via other organisations like Brighter Access.

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If you know of people interested in attending the clinic, the way to connect is via our Contact Page on this website, or via staff at IAS Inverell.

The clinic provides counselling therapies, behaviour support, and some informal group and community social time depending on who is around and whether people have time to share a cuppa. In some cases, individuals decide the clinic is not for them. They may decide to visit us at our Armidale studio.

By providing a regional clinic, IAS Inverell and our therapy service are working to address the sad lack of adequate NDIS funding for travel and therefore the lower rates of access to senior therapist assistance in the New England North West. By hosting this clinic, we are able to drastically reduce travel costs per participant.

January 20, 2018

Functional Assessment and Behaviour Support

Essential really to effective behaviour support, “functional assessment” provides the what, why, when, how, and how much of behaviours of concern. In fact, we have read studies that suggest that functional assessments well done improve the likelihood of your choice of support method by as much as 200%.

That is, base your effort on a functional assessment and your intervention is twice as likely to be useful. By useful we mean that behaviour support based on solid assessment and intervention planning seeks to 1. increase safety wherever possible, 2. provide insight and hope, 3. create options and choices, and 4. reduce behaviours of concern and/or change environments and supports that then contribute to changes in behaviours. In many cases these positive outcomes are documented, accepting the fact that every situation is unique and that there are no guarantees.

However, research and professional practice over many years has shown that behaviour support assessments and interventions, and counselling where appropriate, provide significant assistance to clients, families, and staff of support organisations.

Smith et al (2016) looked at the relationship between biological setting events and problem behaviours. This is helpful as research to date has ironically not examined this in empirical studies. They used a three-step multi-method procedure. This provided a detailed and systematic assessment and intervention plan. They used fatigue as a physical/biological setting event and focused on people with autism spectrum disorder and intellectual disability. Other biological setting events may include eating disorders, sleeping disorders, changes to medication time-frames, mental health disorders, etc…

The process they used was to provide a descriptive analysis that identified individuals and their history relevant to the study. This step parallels our practice of gathering and requesting case history information. Without this a comprehensive assessment is far less likely to be achieved.

Then they worked through a “functional analysis of each participant’s problem behavior in relation to two contextual factors: fatigue and task demands.” This stage goes alongside our using functional analysis as a baseline for assessment and intervention planning.

Finally the researchers evaluated and tailored a multi-component intervention package that addressed 1. the biological context (fatigue) and 2. the psychosocial context (task demands). They naturally concluded that when both these were present, behaviours were more likely to happen and at greater frequency and/or intensity.

By implementing a multi-component intervention to address both the biological setting factor and the behaviours of concern they reported a dramatic reduction in problem behaviour across the study. The implications suggested the utility of the three-step procedure for understanding and assisting with other biological setting events that contribute to behaviours of concern.

Source: Christopher E. Smith^,Edward G. Carr^,Lauren J. Moskowitz^{, 2016,}Fatigue as a biological setting event for severe problem behavior in autism spectrum disorder, Research in Autism Spectrum Disorders, Volume 23, March 2016, Pages 131–144.

January 17, 2017

E-Coaching and Disability Behaviour Support

New England North West and Australia cover such large areas, plus online services for medicine, health, and psychotherapy related services are proven useful and effective. We still look to the literature to gain new insights on ways to use these technologies more effectively.

The following study suggests that distance or “e-coaching” methods are highly effective. We feel that when combined with consistent interventions at home and in the setting where behaviours of concern happen, e-coaching can assist and provides adequate support from a professional specialist.

However, the clinical basis of many assessments and interventions requires at least an initial direct consultation (face to face) whether in the client’s location(s) or in the therapy studio.

Once the therapist has this baseline and when sufficient information is given to the therapist upon which to form a solid assessment, e-coaching i.e. discussions over Skype during an intervention reduce the burden of travel and provide useful support for clients, families, and service providers.

Abstract: “This study examined the effects of e-coaching on the implementation of a functional assessment-based intervention delivered by an early intervention provider in reducing challenging behaviors during home visits. A multiple baseline design across behavior support plan components was used with a provider-child dyad. The e-coaching intervention consisted of weekly training and support delivered via video conferencing software. Results demonstrated a functional relation between e-coaching and early intervention provider implementation of targeted behavior support plan strategies. Furthermore, the child’s challenging behaviors decreased over the course of the study.”

Title: Using e-Coaching to Support an Early Intervention Provider’s Implementation of a Functional Assessment-Based Intervention

Authors: Fettig, Angel PhD; Barton, Erin E. PhD; Carter, Alice S. PhD; Eisenhower, Abbey S. PhD

Source: Infants & Young Children: April/June 2016 – Volume 29 – Issue 2 – p 130–147

(Accessed 10-1-2017)

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January 10, 2017

Behaviour Support 101_2

Last up we defined “Behaviour Support” and looked at behaviours of concern. The key insight was relationship – all behaviours of concern are relational. “Concern” is about the people who relate AND the person with behaviours.

This round we look at the “WHY BOTHER” of things. Let’s begin with a “Demystify Me Moment.”

Demystify Me #2

Behaviour Support does not exist in a vacuum. All behaviour support happens in familial, social, community, legal, legislative national, and international policy contexts.

Go figure! No way! But yes… this is true.

Here are a few of the basic human rights involved in behaviour support practice in families, communities, and nations. These come directly out of international, national, and state based policy and practice standards.

Every person has the right to:

Dignity and respect
Live in and be part of a community
Realise their individual potential and capacity for physical, social, emotional, intellectual, psychological, and spiritual development
Access services on an equal footing to others in society that support a reasonable quality of life
Choose their own lifestyle and to have access to information
Participate in decisions that affect their lives and future
Receive services in a way that results in least restriction of personal rights and opportunities and human freedoms
Address any grievance or complaint without fear or recrimination from service providers including fear of the discontinuation of services
Protection from neglect, abuse, exploitation, and harrassment

Citation:

Behaviour Support: Policy and Practice Manual Part 1, NSW Department of Ageing, Disability and Home Care, 2009

October 29, 2016

Behaviour Support 101_1

This mini-series will explore the nature of behaviour support practices.

First up, what the heck is behaviour support? That sounds so “formal”! So “uptight!”

Well OK.

Demystify Me #1

Behaviour support is about helping a person whose behaviours are at a level of intensity, frequency, or duration that they threaten quality of life and/or physical safety. This danger might exist for the person or for others. The responses of family, community, or support people to the behaviour may lead to restrictions being placed on the person. The responses might lead to avoidance or result in exclusion of the person. To prevent or reduce these kinds of responses, behaviour support seeks to provide positive person-centred solutions.

But this is all too complicated~! Yes… you are right.

What is behaviour then?

To me, behaviour is relationship. You relate to me. I relate to you. We have behaviours.

Our behaviour is our relating to each other. One way or other!

So if all behaviour is relating to each other, then why focus on the person with “behaviours of concern?”

Ah! Wow! Too cool for school !!!

The “concern” when someone is “going off their head” usually focuses on the person. They are doing something wrong, or bad, or notty, or just plain annoying…

But reality is, whenever someone is relating there are two or more people involved. All behaviours of concern happen in relationship to others – even behaviours that happen for someone who is alone in their own room. Say for example, a person who likes to eat their finger nails until they bleed. They do this in their room alone. This is a concern for the others who care about their health and well being. So all behaviours of concern are relational in some way or other.

So now we see the “concern” is really about everyone else plus the person doing the behavior. The “concern” is how can our relationship support the person to reduce or change their behaviour into new more resourceful ways of relating.

Now. When you read the definition of behaviour support above, pull out the word “helping.” Make this big: “HELPING!!!!!! HELPING!!!!!! HELPING!!!!!”

Behaviour support is about helping, creating solutions, and nurturing human relationships. In our way of thinking this is pretty darn important.

Citation:

Behaviour Support: Policy and Practice Manual Part 1, NSW Department of Ageing, Disability and Home Care, 2009

October 25, 2016

Positive Behaviour Support

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Ironic that much of behaviour support language is coached in negative words that sound horrible and clinical. As hopeful as we want to be, this may not change if behaviour support remains driven by psychology as a discipline.

Coming from a holistic framework of Person Centred Psychotherapy, taking a strength based approach tends to reframe language. This makes things more accessible. Less clinical. And more humane.

What is support after all? To support someone is to help them, to enable them, to offer companionship on a journey of change or discovery or just being. Support is listening. Supportive listening opens up doors, paths, and possibilities.

Exploring the possible, we co-design plans – even with people whose profound dis-ability can also be recast into strengths and capacities! Too often people look to what is missing. Seems a natural human tendency. The old glass is mostly empty problem…

But in therapy my take is looking at the fullness of the glass, and going, OMG can you see that? Can you celebrate that? How do you feel when you focus on what great skills you have already? How can we build on that capacity you have now?

Positive behaviour support can move away from managing crisis to engaging in growth, change, and even radical new ways of being in the world. What is my radical might be your boring – but who is to judge my radical but me? Who really knows me, but the people who support me day-in and day-out? Who is able to challenge me and my supporters better than a counselling therapist driven by positive supportive practices?

Please don’t dis my ability. Radically transform my dis-ability into strength-capacity and invig-ability! To invigorate is to build ability and capacity. To give energy to a static body. To move someone that may have felt stuck, or systems or families that were somehow blocked in their energy and patterns and habits of being. Invig-ability is the way to go. No doubt about that!

Joseph Bowers PhD is a Counselling Psychotherapist and registered provider with the National Disability Insurance Scheme.

April 29, 2016

Ability Therapy Specialists Pty Ltd

Individuals, Couples, Families, Children ~ NDIS Registered Provider of Behaviour Support, Counselling Therapies with Creative Arts, Rehabilitation, Employment Job Readiness, Paediatric Early Childhood Intervention ~ Serving Armidale, New England, NSW, Australia and Online

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