INT. J. LANGUAGE & COMMUNICATION DISORDERS, 1998, VOL. 33, SUPPLEMENT

TO ENGAGE OR NOT TO ENGAGE? AFFECTING THE INTERACTIONS OF LEARNING DISABLED ADULTS

Karen Bunning

Dept of Clinical Communication Studies City University

Northampton Square London EClV OHB.

email: kt.bunning@city.ac.uk

An intervention, termed ‘Individualised Sensory Environment’ (ISE), was developed for use with adults with profound and multiple learning disabilities (Bunning 1996). The aim was to affect positively the interactive behaviours displayed by clients in the natural environment: specifically, to reduce the level of non-purposeful engagement, characterised by stereotypic actions, self- injury and neutral behaviour and to increase the levels of purposeful interaction with people and objects. Momentary time sampling was the chosen method of assessment. The results showed that the clients emitted high levels of non-purposeful behaviour at baseline. Post ISE intervention assessment revealed a decline in the level of non-purposeful behaviour and an increase in purposeful interactions.

Introduction

Establishing and maintaining social contact with people who have profound and multiple learning disabilities is often very difficult. A lack of formal linguistic code and the presence of additional sensory and motor impairments may place stresses on the interactive partnership of client and significant other. The non-conventional communication behaviours of these individuals such as body language, facial expression, eye gaze and vocalisations, make them highly dependent on the interpretations of others to make themselves understood. The presence of certain characteristics may disrupt the communicative and social interaction process further. There is a greater incidence of sensory impairment amongst people with a more severe learning disability. The degree of sensory impairment is also likely to be more severe in type as the learning disability increases (Kieman and Kieman 1994).

Abnormal behaviour patterns characterised by a lack of purpose, such as stereotypy or self-injury, may challenge the communicative process. Prevalence of aggression, property destruction, self-injurious behaviour and other forms of challenging behaviour are positively correlated with the degree of learning disability. Multiple forms of problem behaviour are more likely amongst those people with the more severe learning disabilities and those who are non-verbal or experience particular difficulty with reception and expression of language (Kieman and Kieman 1994). Self-injury is closely related to the degree of learning disability: 70% of people who self-injure have a severe-profound learning disability (Oliver et af. 1987). Examining the relationship between challenging

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behaviour and communication difficulties, Chamberlain et al. (1993) found that people with mild learning disabilities, having the skills to verbalise their feelings and internal judgements in a common code of reference with their staff, emitted comparatively fewer problem behaviours.

The relationship between non-purposeful behaviour (in particular stereotypies) and additional sensory impairments has been documented (Kiernan and Kiernan 1994). More specifically Jones et al. (1995) cite studies which relate stereotypic behaviours to individual types of impairment: eye pressing and light gazing in people with visual impairments and multiple stereotypies including self-injury, tongue chewing, hand flapping and putting fingers in mouth in deaf-blind people.

Low levels of purposeful activity provided in facilities for people with severe- profound learning disabilities seems to be a persistent problem. Earlier studies amongst the residents in long-stay institutions revealed low levels of engagement which compared poorly with the levels measured amongst community residents. Although increased and better focused staff attention to residents has been reported in community housing, it has also been suggested that staff-resident interactions are variable in terms of quantity and quality (Emerson and Hatton 1994). Furthermore a higher level of staffing in community housing does not translate directly into increased quantity and quality of interactions (Felce and Perry 1995). In order to avoid the consequences of social isolation and the potential risk in the way significant others respond to them, there is a need for a deliberate approach to interaction (Felce and Lowe 1995).

Sensory-based intervention

An intervention, termed ‘Individualised Sensory Environment’ (ISE), was developed for people with severe-profound and multiple learning disabilities (Bunning 1996). The aims were to reduce the level of non-purposeful engagement characterised either by stereotypic behaviour, self-injury or extreme passivity and to increase purposeful interaction with people and objects. The intervention focused on three major sensory systems: tactile; vestibular and proprioceptive. Tactile stimulation included massaging creams into the participants’ hands, using hand-held massagers and soft brushes. Vestibular stimulation was represented by two opposing forms of stimulation: an excitatory form of arousal, e.g. rotation (angular stimulation of the semi-circular canals which focuses on changes in the rate and direction of the rotations) or a calming motion, e.g. rocking (linear stimulation of the semi-circular canals resulting in a slow, rhythmic pattern of movement). The third sensory modality considered was proprioception or the route by which our brains are informed of our actions in the world.

Method

The participants attended a community-based day centre for adults with learning disabilities. A referral form distributed amongst key-working staff identified 16 participants who did not use formal linguistic code and engaged in noticeable levels of non- purposeful behaviour. The sample population was allocated to therapy groups whose membership ranged from two to four, based on each person’s location within the service’s structure. Groupings were then randomly assigned to two experimental groups, one receiving ISE, the other receiving an attention placebo condition (AP).

388 People with learning diJahilities

The main locus of interest was the level and type of interactive behaviour demonstrated by the participants in the natural environment. It was expected that the introduction of the intervention would effect a change in the engagements of each participant at times outside the actual therapy sessions. A classification system for coding participant engagement which was broadly similar was used:

self-neutral engagement: routine body actions and passively responding to the actions of

self-active engagement: characterised by repetition, irrelevance to any ongoing activity

person engagement: characterised by social contact with at least one other such that they

object engagement: interactive schemes applied to objects and their relations in space,

person-object engagement: combining person and object in one or several fluid actions,

An assessment procedure employing systematic observation techniques termed momentary time sampling (MTS) was used to measure the effects of the intervention. The interval between each data point was fixed at a value of 10 seconds for its absolute error in estimation and the ability to reflect the absence or presence of trend (Brulle and Repp 1984). A delay of three seconds subsequent to the moment to be sampled was set to facilitate the accurate coding of the engagement behaviour. These intervals were signalled to the observer by bleeps played through a headset and the sampled moments of behaviour were recorded on a simple checksheet. Data collection sought to yield the proportion of all sampled moments where the pattern of engagement was occurring within the specified observation time.

Assessment was carried out at baseline and after the phase of therapy. Each participant was observed for 15 minutes on four separate occasions (one hour of observational data). To protect the data from contamination due to the effects of illness or epileptic seizure, no participant was observed for more than 15 minutes in one day. Each group received twice weekly therapy sessions of one hour’s duration for a period of four weeks. Significant others were involved in the delivery of therapy. The therapist performed the role of group manager and was responsible for organising the sessions to meet the individuals’ goals, demonstrating appropriate models of interaction for the significant others and providing feedback on the interactions taking place.

others, e.g. gazing around, fiddling with hair, walking, sitting, etc

and highly predictable feedback, e.g. rocking, self-injury, etc

mutually influence each other, e.g. looking, touching, vocalising, etc

e.g. visual pursuit, fixation, tracking, touching, grabbing, banging, etc

e.g. alternating gaze between person and object, etc

Results

Variations existed between the two groups at baseline assessment (see Figure 1). Group 1 showed a high level of self-active behaviour whilst that of Group 2 was almost half of its level. Group 2 demonstrated a self-neutral level that was practically double that of Group 1.

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50

3 40

2 10

8 30 1 g 20

0

Self- Self-active Person Object Person - neutral object

Dependent Variable: Categories of Engagement

Figure 1. Group differences between levels of engagement at baseline assessment

A two-way analysis of variance (ANOVA) showed that changes in participant engagement over the two assessments were significant (Group 1 after ISE: F = 10.347, d.f = 4, p < 0,0001; Group 2 after AP: F = 5.624, d.f. = 4, p < 0.005). Examination of the simple main effects revealed the different outcomes of the ISE intervention and the placebo condition (AP) regarding the type of engagement (see Table 1). Both groups demonstrated a significant reduction in the level of self--active. The result for Group 2 is presumably a result of the initial effects of extra attention. Conversely, the level of self- neutral was much higher in Group 2 but remained unaffected by the placebo condition. Only Group 1 showed significant gains in purposeful engagement, namely person and object. It seems that, although self--active engagement is sensitive to the extra attention afforded by the attention placebo, it is not sufficient to effect an increase in purposefd engagement.

Table 1. Summary of simple main effects

Engagements Group 1: ISE Group 2: AF’

F P F P self-neutral 0.472 0.5 18 1.601 0.241 self-active 40.045 0.001 14.897 0.005 person 9.387 0.022 1.210 0.303 object 9.035 0.024 0.487 0.505 person-object 2.985 0.135 1.344 0.280

Discussion

The high level of self-uctive engagement in Group 1’s baseline assessment is consistent with a number of studies. Repp et al. (1988) concluded in a review of documented surveys that stereotypic and self-injurious behaviours were indeed common forms of maladaptive responding amongst severely handicapped persons. The prevalence of sensory impairments was higher in Group 1 which may in part account for the inflated level of self-active engagement. Out of the four participants in Group 1 who demonstrated the highest levels of self--active behaviour at baseline, three had diagnosed hearing losses.

390 People with learning disabilities

The presence of sensory impairment may be a factor in the type of non-purposeful behaviour, i.e. self-active, and in relation to its level of occurrence (Kiernan and Kieman 1994).

The environment may affect the engagement levels of learning disabled people and a lack of stimulation may lead to depressed levels of purposeful activity. The television reports from Romania at the end of the 1980’s showed children in institutions displaying classic examples of stereotyped behaviour. Mansell at al. (1982) commented on the low levels of purposehi activity in facilities for persons with severe-profound learning disabilities. McHatton et al. (1988), looking at an institutional population, reported that 70% of the group’s time was spent in neutral engagement prior to its community move, when it decreased. Therefore a relationship between the setting and the behaviour is suggested. The appropriateness of task demands regarding the skills of individuals and the availability of environmental contingencies may be factors in the level of self-neutral behaviour.

The contingency of the ISE stimulation and the type of reinforcement offered may be relevant. Murphy et al. (1986) presented specially adapted toys to learning disabled children which provided potent stimuli in response to their manipulations. A reduction in the occurrence of stereotypies was reported. Conversely, Dehaven et al. (1980) reported little difference in the high levels of stereotypy emitted by participants who were moved from institutional units to rooms with toys and minimal social interaction. The presence of sensory stimuli alone may not be sufficient to affect engagement levels.

The presence of sensory stimuli alone may not be sufficient to affect engagement levels. The organisation of sensory opportunities involved the apprenticeship of the significant others. New skills were acquired in relation to their communication partnerships with the participants. Therefore, the communicative role of the significant other was affected in terms of the quantity and quality of their interactions with the participant. Furthermore staff were observed to take initiatives outside the therapy sessions regarding the presence of contingent stimuli in the environment.

A deliberate approach to interaction may help people with severe-profound and multiple learning disabilities to engage in the social events around them. The participation of significant others is considered crucial to the success of the intervention. When people are in danger of being excluded because of behavioural problems or a lack of social response, some very individual solutions should be explored.

References

Brulle, A.R. and Repp, A.C., 1984, An investigation of the accuracy of momentary time sampling procedures with time series data. British Journal of Psychology, 75, 48 1- 485.

Bunning, K.T., 1996, Development of an ‘Individualised Sensory Environment ’ for Adults with Learning Disabilities and an Evaluation of its Effects on their Interactive Behaviours Unpublished Thesis. (London: City University)

Chamberlain, L., Chung, M.C. and Jenner, L., 1993, Preliminary findings on communication in learning difficulty. British Journal of Developmental Disabilities, 34, 118-125.

Dehaven, E.D., Rees-Thomas, A.H. and Benton, S.V., 1980, Research implications: the use of omission training to reduce stereotyped behavior in three profoundly retarded persons. Education and Training of the Mentally Retarded, 15, 298-305

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Emerson, E. and Hatton, C., 1994, Moving Out: The Effect of the Move from Hospital to Community on the Quality of Life of People with Learning Disabilities (London: HMSO)

Felce, D. and Lowe, K., 1995, The extent of support for ordinary living in staffed housing: the relationship between staffing levels, resident dependency, stawresident interactions and resident activity patterns. Social Science &Medicine, 40, 799-8 10.

Felce, D. and Perry, J., 1995, Adaptive behaviour gains in ordinary housing for people with intellectual disabilities, Journal of Applied Research in Intellectual Disabilities, 9, 101-1 14.

Jones, R.S.P., Walsh, P.G. and Sturmey, P., 1995, Stereotyped Movement Disorders (Chichester: John Wiley)

Kiernan, C. and Kiernan, D., 1994, Challenging behaviour in schools for pupils with severe learning difficulties. Mental Handicap Research, 7, 1 17-20 1.

Mansell, J., Felce, D., De Kock, U. and Jenkins, J., 1982, Increasing purposeful activity of severely and profoundly mentally handicapped adults. Behavioural Research and Therapy, 20,593-604.

McHatton, M., Collins, G. and Brooks, E., 1988, Evaluation in practice: moving from a problem ward to a staffed flat. Mental Handicap Research, 1, 14 1 - 15 1.

Murphy, G., Carr, J. and Callias, M., 1986, Increasing simple toy play in profoundly mentally handicapped children, 11: designing special toys. Journal of Autism and Developmental Disorders, 16,45-57.

Oliver, C., Murphy, G.H. and Corbett, J.A., 1987, Self-injurious behaviour in people with mental handicap: A total population survey. Journal of Mental DeJiciency Research, 31, 147-162.

Repp, A.C., Felce, D. and Barton, L.E., 1988, Basing the treatment of stereotypic and self- injurious behaviours on hypotheses of their causes. Journal of Applied Behaviour Analysis, 21, 281-289.