Effectiveness of Active Support for adults with intellectual disability in residential settings: Systematic review and meta-analysis

BACKGROUND

The review examined the effectiveness of Active Support (RQ1) and stakeholders' experiences of the model (RQ2).

METHOD

Data were meta-analysed (RQ1; studies = 14) and synthesized narratively (RQ2; studies = 10).

RESULTS

By follow-up (6 months post-training), effect sizes (RQ1) for resident total activity engagement were significant and ranged from small (d = 0.33, 95% CIs: 0.10-0.50) to large (Tau-U = 0.95, 95% CIs: 0.64-1.25) depending on study design. Follow-up changes in staff assistance were moderate (d = 0.56, 95% CIs: 0.23-0.89; Tau-U 0.63, 95% CIs: 0.32-0.93) and large for quality of support (d = 1.03, 95% CIs: 0.61-1.44). Other outcomes did not change.

CONCLUSIONS

Active Support was more effective following complete staff training, in larger settings, at lower staff-to-resident ratios and with less experienced staff. Active Support training and outcomes were valued by staff and residents (RQ2), and staff experienced increased job satisfaction. Lower staff turnover and organizational readiness appear crucial for maintaining implementation.

Prevalence of psychotropic medication use and association with challenging behaviour in adults with an intellectual disability. A total population study

BACKGROUND

There is a high prevalence of psychotropic medication use in adults with Intellectual Disabilities (ID), often in the absence of psychiatric disorder, also associated with challenging behaviour. Previous research has focused on specific sample frames or data from primary care providers. There is also a lack of consistency in the definition of challenging behaviour used.

METHODS

We adopted a total population sampling method. Medication data on 265 adults with ID were classified according to the Anatomical Therapeutic Chemical classification system. The Behaviour Problems Inventory - short form classified challenging behaviours. We examined the association between challenging behaviour and the use of psychotropic medication, and whether any association would still be present after accounting for socio-demographic and clinical characteristics.

RESULTS

70.57% of adults with ID were prescribed at least one class of any medication (mean per person =2.62; range 0-14). Psychotropic medications were used by 37.73% of participants with antipsychotics the commonest type used by 21.89% of individuals. Polypharmacy and high dosages were common. Generalised Linear Models indicated significant associations between psychotropic medication and the presence of a psychiatric diagnosis, challenging behaviour, older age and type of residence. Male gender was additionally associated with antipsychotic medication.

CONCLUSIONS

The use of a total population sample identified via multiple routes is less likely to overestimate prevalence rates of medication use. Current challenging behaviour was a predictor of medication use after controlling for other variables. Data indicate that there may be differences in prescribing patterns associated with different topographies of challenging behaviours.

Staff behaviour and resident engagement before and after active support training

BACKGROUND

Identifying the factors associated with greater increases in resident engagement has the potential to enhance the effectiveness of active support (AS).

METHOD

Observational data from Stancliffe, Harman, Toogood, and McVilly's (2007) study of AS were analysed to evaluate amount of staff help, effectiveness of staff help, and staff use of praise.

RESULTS

Lag analyses showed that antecedent staff help was consistently followed by resident engagement at pre-test. This strong association did not increase significantly at post-test. Resident engagement was more likely to follow staff help than the other way around. There was an increase from pre-test to post-test in help and praise by staff. The higher absolute amount of praise was largely the result of the increase in staff help.

CONCLUSIONS

The amount of staff help, its effectiveness, and use of praise by staff may each be important in increasing engagement. These factors should continue to be the focus of research attention and applied efforts to help ensure active support is consistently effective.

Interactive training for active support: perspectives from staff

BACKGROUND

In this study, we describe the experience of participating in interactive training (IT) for active support (AS). Staff (N = 58) working with adults with an intellectual disability (ID) received IT on providing effective assistance for participation in daily activities.

METHOD

Semi-structured interviews were conducted with staff (N = 37) on their experience of IT, the way it affected their work, and their views on the implementation of AS.

RESULTS

High levels of satisfaction with IT were reported. Most staff identified at least one skill learnt during IT that they were still using 8 months later. No clear and consistent picture of AS implementation emerged across the service; staff identified a number of barriers, with lack of managerial support as the most significant.

CONCLUSIONS

Interactive training can directly affect staff behaviour and has the advantage of being positively perceived by staff. However IT alone cannot ensure successful AS implementation, which is affected by a number of other factors, such as managerial support and input, residents' challenging behaviours, and staffing levels.

Interactive training

BACKGROUND

Active support (AS) was developed to help staff organise and deliver practical support for meaningful client engagement in everyday activities. Both the amount and momentary effectiveness of staff support for client engagement have been found to increase following AS training. Training typically consists of a combination of workshops and onsite coaching sessions. To date, onsite training procedures have not been described or evaluated independently of AS workshops.

METHOD

An onsite training procedure used in AS--interactive training (IT)--was evaluated independently of AS workshops through direct observation of staff and client behaviour. Staff views were canvassed via a questionnaire.

RESULTS

Following interactive training, staff assistance and client engagement increased. Staff views on the experience were positive.

CONCLUSIONS

Results from this preliminary study suggest that further research on the effectiveness of interactive training is warranted.

Persistence of challenging behaviours in adults with intellectual disability over a period of 11 years

BACKGROUND

Challenging behaviours in people with an intellectual disability (ID) often develop early and tend to persist throughout life. This study presents data on the chronicity of challenging behaviours in adults with ID over a period of 11 years, and explores the characteristics of people with persistent serious behaviour problems.

METHOD

Support staff provided data on 58 adults living in a long-term residential facility using an interview survey schedule assessing challenging behaviours in 1992 and 2003.

RESULTS

Participants presenting with serious physical attacks, self-injury and frequent stereotypy were the most likely to persist in these behaviours over time. These behaviours were characterised by high persistence percentages and associations over time. However, the earlier presence of serious challenging behaviours did not significantly affect the likelihood of serious challenging behaviours in 2003. Individuals with persisting behaviour problems differed from those who did not present serious behaviour problems on the basis of their younger age, increased mobility, and decreased sociability and daily living skills in 1992.

CONCLUSIONS

Estimates of persistence for challenging behaviours are affected by the statistics chosen to represent stability. The apparent persistence of serious challenging behaviours highlights the need to identify the factors related to maintenance of these behaviours over time. The participant characteristics and adaptive behaviours identified in the present study were not consistently related to the persistence of challenging behaviours. Therefore, other factors, including environmental characteristics, are likely to be related to challenging behaviour persistence.

Opportunity and the promotion of activity among adults with severe intellectual disability living in community residences: the impact of training staff in active support

Active support, a package of procedures which includes activity planning, support planning and training on providing effective assistance, was introduced in five community residences serving 19 adults with severe intellectual disability following a multiple baseline design. The residents were directly observed to ascertain the level of assistance they received from staff and their engagement in activity. The introduction of active support increased the levels of assistance residents received, their engagement in domestic activities and their total engagement in activity. The intervention did not affect the level of social engagement. Across individuals, increases in assistance and engagement in activity were significantly and positively correlated. Both were significantly inversely related to resident adaptive behaviour. At baseline, staff gave more attention and assistance to people who were behaviourally more able. After the introduction of active support, receipt of attention was unrelated to adaptive behaviour and the behaviourally less able received more assistance. The disparity in activity between the more and less able was reduced. Gains were maintained in the majority of houses.

South African oral hygienists: their profile and perception of their profession and career

The aim of the study was to determine a profile of the oral hygienists in South Africa, their views on the profession, work-place, and the practice of their career, which aspects of the work they enjoy and which are not enjoyable, their opinions on expanding duties for hygienists and which duties should be included, and their perceptions about the status and importance of oral hygienists vis-à-vis other health providers. A questionnaire was sent to every third registered oral hygienist and 47 per cent responded. The majority who responded were in the age group 20 to 39 years, had been in practice for less than 15 years, were married, qualified at the Universities of Pretoria and Stellenbosch, and were employed in traditional practice. The larger proportion worked individually and practised from six to eight hours per day. They were happy with the training they received, believed their job was worthwhile, were satisfied with their careers and enjoyed a cordial relationship with dentists. Motivating, educating, assisting patients and communicating with people were the most enjoyable aspects of practice while procedures associated with the treatment of gingivitis and periodontitis and the poor response of patients to treatment were the least enjoyable. The majority preferred expanded duties for hygienists which should include elementary dentistry, local anaesthesia, minor extractions and emergency treatment and they also desired greater independence. Seventy-eight per cent felt that the public does not know what oral hygiene is. The status and importance of the profession were rated comparable to that of physiotherapists, qualified nurses, radiographers and dental therapists but significantly higher than dental assistants.

Diet, physiological work and accident incidence of forge workers

Three experiments were made to study the following three factors in forge workers in a hot shop: (a) the metabolic load of daily work, (b) dietary intake, and (c) the effect of supplementing morning dietary intake with glucose syrup ingestion upon accident incidence. High energy output, mean 9.7 MJ (2,300 kcal), complemented high energy intake, mean 15 MJ (3,600 kcal), a shortage of intake in the morning being compensated for after work in the evening. Alcohol intake represented 1 to 2 MJ (240 to 480 kcal) of the evening intake. Glucose syrup ingestion to reverse increased use of fats in the metabolic fuel in the early morning, in a double-blind design, resulted in a significant reduction of accidents. The effect may lie in altered levels of 5-hydroxytryptamine in the central nervous system. Caution in interpreting the effect upon accidents is necessary since the number of subjects was small (57) and the time span limited (18 weeks).