Working with Young People with Autism and AggressionProfessor Dave Dagnan Consultant Clinical Psychologist, Cumbria Partnership NHS Foundation Trust and Institute for Health Research, University of Lancaster

dave.dagnan@cumbria.nhs.uk

What do we know about aggression in people with Autism?Levels of aggression in general intellectual disability population vary depending on definition of aggression but aggression towards others 11-22% and higher in some studies: aggression higher in those withgreater degrees of intellectual disabilitysensory disabilitiesdifficulties in languagepoor problem-solving and coping skillspoor social skills and poor social supportadditional psychiatric disordersIn intellectual disability populations ASD is not usually found to be a predictor of aggression

dave.dagnan@cumbria.nhs.uk

What do we know about aggression in people with Autism?People with more severe ASD may show less aggression than those with milder symptoms In populations of younger people with intellectual disabilities aggression persists over 5-11 years at a level of around 70+%Some studies suggest that persistence of behaviour is associated with ASD symptoms50% of people with intellectual disabilities who have challenging behaviour are physically restrained.Aggression has significant effect on carers, people who live with the person and the person themselves

dave.dagnan@cumbria.nhs.uk

What guides our work in this area?The evidence baseNational guidance (NICE)Clinical consensus good practice guidesLiterature and shared experienceOur own researchThe local contextThe geography of CumbriaStrengths and weaknesses of partner organisations

dave.dagnan@cumbria.nhs.uk

UK/English Guidancehttp://www.library.nhs.uk/learningdisabilities/

dave.dagnan@cumbria.nhs.uk

UK/English Guidancehttp://www.library.nhs.uk/learningdisabilities/

dave.dagnan@cumbria.nhs.uk

Managing Aggression: A Positive FrameworkFunctional analysisSubstantial assessment of:The individualThe immediate social settingsThe wider social and educational, work, leisure settingsClear risk assessment processesMaintaining value baseNon-aversive interventionsUnderstanding the legal frameworks

dave.dagnan@cumbria.nhs.uk

Managing Aggression: A Positive FrameworkMulti-component interventionsDistinguishing positive and emergency/safety interventionsEmphasis upon lifestyle changeChanging what happens before the behaviour, not what happens afterwardsLinks to care coordinationTeaching adaptive skillsTo young people and carersTherapeutic interventionsTo young people and carers

dave.dagnan@cumbria.nhs.uk

Managing Aggression: A Positive FrameworkCapacity building Training and consultationWell trained staff Well managed organisationsEvaluate outcomesAudit of standards

dave.dagnan@cumbria.nhs.uk

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dave.dagnan@cumbria.nhs.uk

How we deliver this in CumbriaUniversal integrated services. Specialist services that add value to generic serviceslocated in 3 sectors across CumbriaCombined adult/child challenging behaviour team in total; 7 senior nurses, 9 staff nurses, 3 psychologists, 3 support workersWe insist our teams have high levels of expertiseClosely integrated with Social Work disability teams and, very good working relationships with Child and Adolescent and Adult Mental Health teams and criminal justice systemsExpect to work with people over long periods of time, and expect to be supporting some young people into adult services

dave.dagnan@cumbria.nhs.uk

Referral to serviceStructured behaviouralproblem solvingIntensive behavioural interventionEcological systemic supportIntensive modellingReviewAllocation to challenging behaviour pathwayThe Cumbria PathwayCognitive Therapy

dave.dagnan@cumbria.nhs.uk

What is our goal in working with people with challenging behaviour?The aim of working with people with challenging behaviour is to achieve a high quality of life for carers, people who live with people who challenge and people themselves despite the setbacks that we will inevitably experience.Allocation to challenging behaviour pathway

dave.dagnan@cumbria.nhs.uk

Structured behavioural problem solvingAssessmentRisk AssessmentHealth AssessmentTopographical/Outcome measureFunctional interview (ONeil)Psychiatric Screen (PASSAD)Sensory ScreenAdaptive Behaviour AssessmentCommunication/Intellectual FunctioningStaff/Family confidence/beliefs

Structured behaviouralproblem solving

dave.dagnan@cumbria.nhs.uk

Structured behavioural problem solvingShared FormulationStructured behaviouralproblem solving

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Structured behavioural problem solvingShared Formulation through a cognitive/training processWhat do we need to work with aggressive behaviour?What are our goals in this work?How do we feel and think about aggressive behaviour?Introduce behavioural modelApply the model to client and carersDevelop a shared formulationDevelop interventions that are based in formulation.

Structured behaviouralproblem solving

dave.dagnan@cumbria.nhs.uk

Structured behavioural problem solvingInterventionSafety StrategyCommunication StrategyLifestyle ChangeCase managementReview

Structured behaviouralproblem solving

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ConclusionsWorking positively with people with autism with aggressive behaviour in staffed and family homes requires structured clinical processes operating within clear ethical and legal frameworks.

dave.dagnan@cumbria.nhs.uk

Referral to serviceStructured behaviouralproblem solvingIntensive behavioural interventionEcological systemic supportIntensive modellingReviewAllocation to challenging behaviour pathwayThe Cumbria PathwayTherapy

dave.dagnan@cumbria.nhs.uk

Physical InterventionGood PracticeDefinition of physical interventionDirect physical contact between a carer and a person with challenging behaviour (e.g., self-protective 'breakaway' techniques for escaping from grabs and chokes or minimal restraint to briefly immobilise the person)The use of barriers, such as locked doors, to limit freedom of movementThe use of materials or equipment to restrict or prevent movement (e.g., the use of arm splints to reduce self-injury; lap belts)

dave.dagnan@cumbria.nhs.uk

Physical InterventionGood PracticeImportant principles in physical intervention should be reflected in organisational policiesPhysical interventions should only be used in the best interests of the person with learning disabilitiesThey should only be used in conjunction with other strategies to help people learn to behave in non-challenging waysThey should be individualised and subject to regular review They should employ minimal force and not cause pain

dave.dagnan@cumbria.nhs.uk

Managing Challenging Behaviour in Cumbriadave.dagnan@cumbria.nhs.ukManaging Challenging Behaviour in Cumbriadave.dagnan@cumbria.nhs.uk