In a recent radio interview, Prof Chris Bigby, Director of La Trobe’s Living with Disability Research Centre in Australia, highlighted that individuals living with severe intellectual disability generally receive 6 minutes of direct time with their supports every hour. The aim of this radio segment was to highlight the need to increase choice and control in the lives of people with intellectual disability, which is the central aim of the National Disability Insurance Scheme, currently being rolled out across Australia.

Thus, non-intervention is a critical issue for those with intellectual disability, particularly those who may currently have things done ‘for’ or ‘to’ them, rather than being supported to do things themselves. Another potentially harmful form of non-intervention is in relation to self-injurious behaviour.

The term challenging behaviour has been used by disability advocates to shift attention away from blaming individuals to locating behaviours as understandable responses to often unstimulating, inflexible, dehumanising and unresponsive services (Hudson and Radler, n.d.).

These behaviours may challenge systems to become better and more responsive (Hudson and Radler, n.d.) Among challenging behaviours, self-injurious behaviours is one demanding attention from supports and services.

In this article, Konstantinos Ntinas reviews the literature relating to behavioural interventions for self-injurious behaviours, aiming to present implications from the literature for training and managerial support.

Summary of the review

Reviews of extant literature can provide useful summaries, and, in the cases of systematic reviews and meta-analyses, a high standard of evidence to better understand what we know, collectively, about a specific body of research. As a researcher who must be across a range of topics and issues, reviews help me to understand a literature quickly and to understand where research gaps lie. Reviews are also useful for time-poor professionals including practitioners and managers.

In addition to describing content, it is essential that reviews are clear about:

1. their research question,
2. their search methods,
3. the strengths and limitations of the research reviewed,

so that the reader can contextualise the content and the approach taken by the review author to their given topic.

Unfortunately, in this review, it is entirely unclear whether a research question guided the author’s narrative review, which search methods elicited the papers discussed, and whether the quality of the papers presented allow us, as readers, to believe their findings.

Although the aim of the article is to “critically analyse the literature concerning the factors that lead to non-interventionism” the author presents more of a description of the barriers managers may face when encouraging practitioners to intervene in the lives of those with intellectual disability, without a robust discussion of what appropriate interventions may look like, and whether and how they are in the best interests of those with intellectual disability themselves.

The author presents the review across three parts. First, the author presents literature that presents research evidence as it relates to:

Practitioners’ behaviour analytic skills: referring to the ability to “identify the function of self-injurious behaviour and link an intervention to it”. Particularly in the context of the challenging behaviours as “understandable responses” as described above, I found it confusing that the author notes the identification of the function of behaviours is not an issue “of high concern”.

I’m not sure if the author is saying that the literature has found that practitioners do not prioritise this, or if the literature suggests that identifying the function of behaviours is actually unimportant.

Practitioners’ emotional responses to self-injurious behaviours: interestingly, the author focuses on emotional responses to the behaviour itself, rather than responses to the individuals who are engaging in the behaviour. This is a subtle, but important distinction, which is apparent throughout the article: people with intellectual disability are not at the forefront of the review.

Here, it is also highlighted that differences exist between more and less experienced practitioners in terms of negative emotions and responses to these behaviours.

In the second part, the author shifts focus to discuss the implications of the literature on training, in relation to:

Emotional empowerment of practitioners: highlighting mindfulness training as a potential approach, in collaboration with behavioural training and development of technical skills.

Technical empowerment of practitioners: including brief workshops and trainers who gain staff support and commitment. .

Emphasis should be given to the ‘escape from demands function’ but the author doesn’t describe what this is. A brief mention of the importance of highlighting the benefits of practice for the wellbeing of individuals is made.

Third, the author explores implications for managerial support. Here the focus is really on “what” rather than “how”. The author indicates that managers should identify practitioners most in need of training and provide them with adequate support, but doesn’t articulate how to identify those most in need apart from working with those with less experience.

The author indicates it is important to increase willingness to participate in training, and for managers to support post-training for practitioners to carry out their roles, but both of these suggestions seem incredibly difficult to achieve in any organisation let alone those that are time poor or have to prioritise staff-client time over staff training.

Managers are also encouraged to reduce perceptions of inequity within organisations, and provide incentives for those more exposed to self-injurious behaviours.

Strengths and limitations

A strength of the paper is that, as a review, it offers a summary of literature in an accessible form for practitioners and researchers interested in gaining a snapshot view of this topic. Quite a number of papers are reviewed and synthesised to present a readable narrative.

I have already highlighted my major concern with the paper – the lack of transparency about how the papers were found, critiqued and what research question (if any) was guiding the author’s review of these papers. Many are very dated – from the 1980s and 1990s. Admittedly the author discloses this explicitly to readers, but doesn’t offer an explanation of whether this is the only literature available or why this important topic has not received more recent attention.

With respect, I do feel that individuals with intellectual disability could have been given more central stage in this paper – the causes, consequences and implications of self-injurious behaviours could have been explored in detail. Without their presence in this paper, I felt confused about the strategies offered to managers to support their staff.

There were many “what to do’s” suggested without much space given to “how” these strategies might be implemented. Aspirational strategies are important and we should all aim high in our work, but pragmatics are important when offering directed advice.

Perhaps though, the nature of the author’s recommendations reflect the lack of literature offering pragmatic advice to date. The search strategy used by the author would be helpful to determine if this is true.

Given the focus on barriers and lack of focus on people with intellectual disability themselves, I would be cautious in recommending this paper to practitioners or individuals with disability, but managers may find some of the strategies useful.

Conclusion

The author concludes that the “limited behaviour analytical skills of practitioners impede the implementation of behavioural interventions and allow self-injurious behaviours to persist.”

Also, “further research on the implementation of policies of training and managerial support towards non-intervention is needed in order to establish which are more effective.”

Ultimately, this article made me think of the quote from Albert Einstein: “We cannot solve problems with the same kind of thinking we used when we created them”: as we gain knowledge about how to communicate more effectively with people about their needs, and about how to support those who work with them to avoid burnout, stress and distress, we need to apply such knowledge to such a complex and harmful issue as self-injurious behaviours.

Links

Ntinas, K.M. (2014) Self-injurious behaviour, non-interventionism and practitioners’ needs: Implications for training and managerial support. Journal of Intellectual Disabilities, 18(3):238-248 [abstract]

National Disability Insurance Agency. (n.d) National Disability Insurance Scheme. Available at: http://www.ndis.gov.au/. Accessed on 9 March 2015.

ABC, Radio National (2015) Control and choices for people with intellectual disabilities, presented by Natasha Mitchell. Available at: http://www.abc.net.au/radionational/programs/lifematters/active-support/6083202. Accessed on 9 March 2015.

Hudson, A., and Radler G., (n.d.) Psychologist and intellectual disability. Available at http://www.psychology.org.au/publications/inpsych/disability/. Access on 9 March 2015.

Comments by the author (Dr Ntinas)

Non-interventionism towards challenging behaviors is my primary research aim as it can be seen in my previous research work.

The article in question, which I humbly believe should not be treated as just a review, epitomizes the most significant research in order to provide workable and research based solutions. This I think is its major contribution and I do hope that fellow trainers and administrators will find it a helpful map for action.

Nothing will change as long as the emphasis of training is on the understanding of the behavioral function and not on the ability to link function with intervention especially when the behavior functions as escape from demands. And again nothing will change if we do not take into account that usually the most resistant practitioners to change and to training are the exhausted ones.

Last but not least, please allow me to thank Dr. van Dooren for her effort. I agree with her comment on people with challenging behaviors but it was outside the main scope of the paper in question.  On the other hand, since such behaviors are often the main learners’ means to communicate their needs I am sure that she will agree that as long as we understand the role of these behaviors as well as their impact on staff we might provide staff training and support which ultimately will improve the quality of life of the learners.   

With esteem,
Konstantinos M Ntinas PhD
Headteacher of the Special School of Giannouli
Larisa Greece
ntinask@windtools.gr

After the completion of his studies in Wales (Diploma in severe learning difficulties, Med in management of special needs education, PhD in self-injurious behavior) offered his skills in the field of practice (headteacher) and of training (PBS, ABA).