FR/ID/08 Challenging behaviour: a unified …

1 FACULTY REPORT FR/ID/08 2016 The Royal College of PsychiatristsChallenging behaviour: a unified approach updateClinical and service guidelines for supporting children, young people and adults with intellectual disabilities who are at risk of receiving abusive or restrictive practicesReport from the Faculties of Intellectual Disability of the Royal College of Psychiatrists and the British Psychological Society on behalf of the Learning Disabilities Professional SenateLearning Disabilities Professional SenateFaculty Report FR/ID/08 April 2016 2016 The Royal College of PsychiatristsThe Royal College of Psychiatrists is a charity registered in England and Wales (228636) and in Scotland (SC038369).Contents1 ContentsContributors 2 Foreword 3 Executive summary 4 Background and purpose 6 Values and definitions 8 Roles, skills and responsibilities 10 Multidisciplinary working 12 Working with commissioners 14 References 15 2 Primary editors and authorsDr Roger Banks, Honorary Senior Lecturer, Bangor University, Psychiatrist in Intellectual DisabilityDr Alick Bush, Clinical Psychologist, previous Chair, Intellectual Disability Faculty, Division of Clinical Psychology, British Psychological Society and previous Chair, Learning Disabilities Professional SenateOther contributorsGeoff Baines, Peter Baker, Jo Ball, Sarah Bernard, Harm Boer, Jill Bradshaw, Sue Carmichael.

2 Viv Cooper, Nick Gore, Gemma Griffith, Richard Hastings, Crispin Hebron, Tony Holland, Maria Hurman, Anu Iyer, Freddy Jackson Brown, Edwin Jones, Theresa Joyce, Kathy Lowe, Jane McCarthy, Peter McGill, Jo Poynter, Alan Rosenbach, Ashok Roy, Alex Ruck Keene, Genevieve Smyth, members of the National Forum, members of Speak Up Rotherham, and the current and past members of the LD Professional Behaviour: a unified approach Update is a revised and updated clinical and service guideline for supporting children, young people and adults with learning disabilities who are at risk of receiving abusive or restrictive practice. This guideline is jointly pro-duced by the intellectual disability faculties of the Royal College of Psychiatrists and the British Psychological Society on behalf of the Learning Disabilities Professional Senate. Services for this group of people vary in the quality of the support they deliver.

3 Although there are numerous examples of high-quality local services that are person-centred and support people in achieving a good quality of life, at the other end of the spectrum there have been shocking examples of abusive practice, such as at Winterbourne View. We feel that what is needed now is not another weighty report on Challenging behaviour but rapid action, such as that proposed in the Transforming Care programme. This is a view strongly supported by people with intellectual disabilities and their families, who feel let down at the perceived lack of progress and have become cynical about the reports that have appeared at regular intervals since the original College have therefore decided not to rewrite Challenging Behaviour: a unified approach , instead we have produced a brief, user-friendly how to guide that is easy to use and has an up-to-date reference list for additional resources. The original document remains a useful reference source and the NICE guidelines are also now available for use.

4 In addition, the Learning Disabilities Professional Senate has provided guidance on the role and function of community teams and there is reference to guidance for hope that, armed with this information, we will be able to develop high-quality, consistent, local, person-centred services for a group of citizens who may have justifiably felt let down at times in the Ashok RoyChair, Faculty of Psychiatry of Intellectual Disability, Royal College of Psychiatrists and Clinical Advisor, Health Education EnglandDr Karen Dodd Vice Chair, Intellectual Disability Faculty, Division of Clinical Psychology, British Psychological Society and Co-Chair, Learning Disabilities Professional SenateForeword 4It is our belief that people who present behavioural challenges can and should be supported in living close to home, integrated within the community, engaged in activities that promote optimum quality of life and with support that ensures protection of their human rights.

5 They should not be subject to inappropriate, punitive or harmful restrictions, ineffective treatments or unjustified and excessive use of medication. z Challenging behaviour is a socially deter-mined construct. Reiteration of this construct and its accepted definition is necessary to focus assessment, formulation and inter-ventions on the relationship between the individual and their environment, rather than on the elimination of behaviours . zEffective and safe support of people who present significant behavioural challenges can, and does, occur in integrated community settings. zProfessionals should work with the individ-ual, families, providers and other community resources to deliver interventions and support. zHospitals and large-scale residential settings are not acceptable alternatives to providing integrated and comprehensive care that is close to home. zInterventions delivered as part of care and treatment plans must be based on a clear, comprehensive and agreed formulation and diagnosis.

6 ZPriority outcome measures for interventions should focus on quality of life and the protec-tion of human rights. zClinical services should prioritise early inter-vention and a lifelong, seamless approach that delivers proactive and effective planning for periods of transition. zEffective responses to behavioural challenges will involve clinicians collectively taking and managing risk, adopting new, creative and Executive summaryflexible ways of working, and drawing on a wide range of potential therapeutic interven-tions to ensure that people receive the right support, in the right place, at the right time. zThe majority of individuals who present behavioural challenges are well known to services. The focus of the work of community intellectual disability teams must therefore be on planned, proactive and responsive risk management, ongoing positive-behaviour support for these individuals and the reduction of restrictive interventions.

7 ZClinicians have a responsibility to work in part-nership in a responsive, mutually supportive and facilitative manner with the individual, families, social services and commissioners and colleagues across all sectors. zThe teaching, development and appraisal of clinical skills, competences and practice need to reflect clinical evidence, particularly that published in NICE and other professional guidance. zIt is essential to work closely with families. Clinicians need to understand that families can be vital partners in enabling better under-standing and support of an individual who presents behavioural challenges. Families can also be traumatised, distressed, angry and at times dysfunctional. Clinicians must have and continually develop the skills to be able to engage families (and other non-familial systems) in working on and resolving these issues. zClinicians have a significant role in enabling and empowering individuals with intellectual disabilities and their families.

8 This must be an integral part of any care and treatment plan. zClinicians should be prepared to take the lead in ensuring continuity of care coordination, care and treatment plans, and discharge plan-ning for individuals admitted to hospitals or other institutions away from their local summary5 zClinicians should be very aware of when per-verse financial incentives are shaping and driving decisions about appropriate care and treatment. They should not engage with this and should be prepared to challenge it. zClinicians should be open to challenges of their opinions and treatment plans and should work constructively in response to such challenges to empower people with intellectual disabilities, their families, experts by experience, and others (through such pro-cesses as Care and Treatment Reviews) to be able to work in real partnership to commonly agreed goals. zClinicians should advise and support com-missioners in avoiding models of care that are not consistent with the principles of care, treatment and professional practice laid out in this document.

9 6 This brief update builds on, and should be read together with, the College Report known as CR144 Challenging Behaviour: a unified approach (Royal College of Psychiatrists et al, 2007). Both have the following aims: zto deliver an authoritative consensus of clini-cal opinion, experience and evidence-based practice; zto provide a unified framework for best prac-tice in multidisciplinary clinical and social interventions and support; zto encourage and guide the provision of creative, flexible and effective responses to individuals who present behavioural challenges; zto reduce inappropriately restrictive or inflexible service responses ( long-term admission to hospital, restraint, routine and long-term seclusion, excessive or inappropri-ate use of psychotropic medication); zto support national initiatives to reduce the number of people with intellectual disabilities in hospital settings.

10 Zto promote partnership working across the healthcare, social-care and third sectors (in particular between service developers and commissioners), as well as with individuals and their families; zto promote comprehensive and effective local support and services and to reduce the number of individuals who are failed by current service underlying aim of these reports is to improve the quality of life of people who present behavioural challenges to families and services. The continu-ing emergence of evidence of poor-quality care and abuse in settings such as Winterbourne View (Department of Health, 2012) and the subsequent scrutiny of service provision and performance demonstrate, however, that these and other widely available and referenced policy documents, such as the Mansell Report (Department of Health, Background and purpose2007) in themselves have not improved support for people who present behavioural challenges.