Abstract
Objectives
Reducing and eliminating the use of Restrictive Practices (RPs) is consistent with the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD). This systematic review examines the effectiveness of organisation-wide interventions in reducing behaviours of concern (BoC) and the use of RPs in people with a neurodevelopmental disorder (NDD).
Methods
19 electronic databases were searched up to February 2021 for literature, with no language restrictions applied. This systematic review of interventions included any publication aimed at reducing the use of RPs and/or BoC in organisations providing services to people with any NDD.
Results
A total of 15 studies were included in the review. Seven were randomised controlled trials (RCTs) and eight non-RCTs. Most studies focussed on workplace education and training. There was evidence that staff training in Positive Behaviour Support (PBS) and mindfulness-based PBS (MBPBS) reduced aggression, the use of chemical and physical restraints, and peer and staff injuries (MBPBS) in the medium term. A multi-component intervention also showed evidence of a reduction in behaviours of concern in the medium and long term.
Conclusions
A number of studies showed that organisation-wide PBS training, particularly MBPBS training, can reduce BoC and the use of RPs. One multi-component study also substantially reduced BoC. Organisational strategies such as these can improve the rights of people with disability by reducing the use of RPs. However, the generalisability of these findings may be limited as all comparisons were single studies which had potential biases. We are also not able to say whether these findings can be generalised to children, and adults with other neurodevelopmental disabilities, as all but one study focused on adults with intellectual disabilities.
Similar content being viewed by others
References
Botterill, S., Cottam, S., Fowke, A., & Theodore, K. (2019). “It put control back onto my family situation”: Family experiences of positive behaviour support. Advances in Mental Health and Intellectual Disabilities, 13(3/4), 91–101. https://doi.org/10.1108/AMHID-11-2018-0049
Bruinsma, E., van den Hoofdakker, B. J., Groenman, A. P., Hoekstra, P. J., de Kuijper, G. M., Klaver, M., & de Bildt, A. A. (2020). Non-pharmacological interventions for challenging behaviours of adults with intellectual disabilities: A meta-analysis. Journal of Intellectual Disability Research, 64(8), 561–578. https://doi.org/10.1111/jir.12736
Carr, E. G., Dunlap, G., Horner, R. H., Koegel, R. L., Turnbull, A. P., Sailor, W., Anderson, J., Albin, R., Kern Koegel, L., & Fox, L. (2002). Positive behaviour support: Evolution of an applied science. Journal of Positive Behaviour Interventions, 4(1), 4–16. https://doi.org/10.1177/109830070200400102
Chan, J., French, P., & Webber, L. (2011). Positive behavioural support and the UNCRPD. International Journal of Positive Behavioural Support, 1(1), 7–13.
Chan, J., LeBel, J., & Webber, L. (2012a). The dollars and sense of restraint and seclusion. The Journal of Law and Medicine, 20(1), 73–81.
Chan, J., Arnold, S., Webber, L., Riches, V., Parmenter, T., & Stancliffe, R. (2012b). Is it time to drop the term ‘challenging behaviour’? Learning Disability Practice, 15(5), 36–38.
Chan, J. (2016). Challenges to realising the Convention on the Rights of Persons with Disabilities (CRPD) in Australia for people with intellectual disability and behaviours of concern. Psychiatry, Psychology and Law, 23(2), 207–214. https://doi.org/10.1080/13218719.2015.1039952
Cohen, J. (1988). Statistical power analysis for the behavioural sciences (2nd ed.). Erlbaum.
Craig, J. H., & Sanders, K. L. (2018). Evaluation of a program model for minimising restraint and seclusion. Advances in Neurodevelopmental Disorders, 2(4), 344–352. https://doi.org/10.1007/s41252-018-0076-2
Cusack, P., Cusack, F. P., McAndrew, S., McKeown, M., & Duxbury, J. (2018). An integrative review exploring the physical and psychological harm inherent in using restraint in mental health settings. International Journal of Mental Health Nursing, 27(3), 1162–1176. https://doi.org/10.1111/inm.12432
Denne, L. D., Gore, N. J., Hughes, J. C., Toogood, S., Jones, E., & Brown, F. J. (2020). Implementing evidence-based practice: The challenge of delivering what works for people with learning disabilities at risk of behaviours that challenge. Tizard Learning Disability Review, 25(3), 133–143. https://doi.org/10.1108/TLDR-05-2020-0009
Deveau, R., & Leitch, S. (2014). The impact of restraint reduction meetings on the use of restrictive physical interventions in English residential services for children and young people. Child: Care, Health and Development, 41, 587–592. https://doi.org/10.1111/cch.12193
Dunlap, G., & Fox, L. (2007). Parent-professional partnerships: A valuable context for addressing challenging behaviours. International Journal of Disability, Development and Education, 54(3), 273–285. https://doi.org/10.1080/10349120701488723
Duxbury, J. A. (2015). The Eileen Skellern lecture 2014: Physical restraint: In defence of the indefensible? Journal of Psychiatric and Mental Health Nursing, 22(2), 92–101. https://doi.org/10.1111/jpm.12204
Emerson, E., Kiernan, C., Alborz, A., Reeves, D., Mason, H., Swarbrick, R., Mason, L., & Hatton, C. (2001). The prevalence of challenging behaviours: A total population study. Research in Developmental Disabilities, 22(1), 77–93. https://doi.org/10.1016/S0891-4222(00)00061-5
EPOC (Effective Practice and Organisation of Care). EPOC taxonomy 2015; http://epoc.cochrane.org/epoc-taxonomy [accessed 10th January 2023].
Hariton, E., & Locascio, J. J. (2018). Randomised controlled trials – The gold standard for effectiveness research: Study design – Randomised controlled trials. BJOG : An International Journal of Obstetrics and Gynaecology, 125(13), 1716. https://doi.org/10.1111/2F1471-0528.15199
Hassiotis, A., Poppe, M., Strydom, A., Vickerstaff, V., Hall, A., Crabtree, J., Omar, R., King, M., Hunter, R., Bosco, A., Biswas, A., Ratti, V., Blickwedel, J., Cooper, V., Howie, W., & Crawford, M. (2018). Positive behaviour support training for staff for treating challenging behaviour in people with intellectual disabilities: A cluster RCT. Health Technology Assessment, 22(15), 1–110. https://doi.org/10.3310/hta22150
Hassiotis, A., Robotham, D., Canagasabey, A., Romeo, A., Langridge, D., Blizard, R., Murad, S., & King, M. (2009). Randomised, single-blind, controlled trial of a specialist behaviour therapy team for challenging behaviour in adults with intellectual disabilities. American Journal of Psychiatry, 166(11), 1278–1285. https://doi.org/10.1176/appi.ajp.2009.08111747
Hastings, R. P., Gillespie, D., Flynn, S., McNamara, R., Taylor, Z., Knight, R., Randell, E., Richards, L., Moody, G., Mitchell, A., Przybylak, P., Williams, B., & Hunt, P. (2018). Who’s challenging who training for staff empathy towards adults with challenging behaviour: Cluster randomised controlled trial. Journal of Intellectual Disability Research, 62(9), 798–813. https://doi.org/10.1111/jir.12536
Hayward, B. A., McKay-Brown, L., & Poed, S. (2022). Geographical networks in the divergence of Australian Positive Behaviour Support policy. Journal of Policy and Practice in Intellectual Disabilities, 19(2), 220–229. https://doi.org/10.1111/jppi.12398
Huckshorn, K.A. (2006). Six core strategies for reducing seclusion and restraint use. Available from http://www.nasmhpd.org/content/six-core-strategies-reduce-seclusion-and-restraint-use [accessed 1 March 2023].
Iffland, M., Xu, J., & Gillies, D. (2021). Organisational interventions for decreasing the use of restrictive practices with children or adults with an intellectual or developmental disability. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD013840
Inoue, M. (2017). Assessments and interventions to address challenging behaviour in individuals with intellectual disability and Autism Spectrum Disorder in Japan: A consolidated review. Yonago Acta Medica, 62(2), 169–181. https://doi.org/10.33160/yam.2019.06.001
Kanne, S., & Mazurek, M. (2011). Aggression in children and adolescents with ASD: Prevalence and risk factors. Journal of Autism and Developmental Disorders, 41(7), 926–937. https://doi.org/10.1007/s10803-010-1118-4
Klaver, M., de Bildt, A., Bruinsma, E., De Kuijper, G., Hoekstra, P. J., & Van den Hoofdakker, B. (2020). First steps towards positive behaviour support in the Netherlands: A pilot study exploring the effectiveness of a training for staff. Journal of Policy and Practice in Intellectual Disabilities, 17(3), 188–194. https://doi.org/10.1111/jppi.12334
Lawrence, D., Bagshaw, R., Stubbings, D., & Watt, A. (2021). Restrictive practices in adult secure mental health services: A scoping review. International Journal of Forensic Mental Health, 21(1), 68–88. https://doi.org/10.1080/14999013.2021.1887978
Leoni, M., Cavagnola, R., Chiodelli, G., Corti, S., Fioriti, F., Galli, M. L., Michelini, G., Miselli, G., & Uberti, M. (2018). The reduction of mechanical restraints and PRN medication in 400 persons with neurodevelopmental disorders: An analysis of 11 years process in 23 Italian residential settings. Advances in Neurodevelopmental Disorders, 2(4), 353–361. https://doi.org/10.1007/s41252-018-0087-z
Lepping, P., Masood, B., Flammer, E., & Noorthoorn, E. (2016). Comparison of restraint data from four countries. Social Psychiatry and Psychiatric Epidemiology, 51(9), 1301–1309. https://doi.org/10.1007/s00127-016-1203-x
Limbu, B., Unwin, G., & Deb, S. (2021). Comprehensive assessment of triggers for Behaviours of Concern Scale (CATS): Initial development. International Journal of Environmental Research and Public Health, 18(20), 10674–10674. https://doi.org/10.3390/ijerph182010674
Lombardi, M., Vandenbussche, H., Claes, C., Schalock, R. L., De Maeyer, J., & Vandevelde, S. (2019). The concept of Quality of Life as framework for implementing the UNCRPD. Journal of Policy and Practice in Intellectual Disabilities, 16(3), 180–190. https://doi.org/10.1111/jppi.12279
MacDonald, A., McGill, P., & Murphy, G. H. (2018). An evaluation of staff training in positive behavioural support. Journal of Applied Research in Intellectual Disabilities, 31(6), 1046–1061. https://doi.org/10.1111/jar.12460
Mahon, D., Walsh, E., Holloway, J., & Lydon, H. (2022). A systematic review of training methods to increase staff’s knowledge and implementation of positive behaviour support in residential and day settings for individuals with intellectual and developmental disabilities. Journal of Intellectual Disabilities, 26(3), 732–757. https://doi.org/10.1177/17446295211022124
McGill, P., Vanono, L., Clover, W., Smyth, E., Cooper, V., Hopkins, L., Barratt, N., Joyce, C., Henderson, K., Sekasi, S., Davis, S., & Deveau, R. (2018). Reducing challenging behaviour of adults with intellectual disabilities in supported accommodation: A cluster randomised trial of setting-wide positive behaviour support. Research in Developmental Disabilities, 81, 143–154. https://doi.org/10.1016/j.ridd.2018.04.020
McLees, E.E. (1994). The effects of empathy skills training: Group interventions with adults with mild retardation and their direct care staff [PhD thesis]. Dissertation Abstracts International, 1995, 55(8-B), 3573, 1-199. ISBN 9798641804781
Miller, J. A., Hunt, D. P., & Georges, M. A. (2006). Reduction of physical restraints in residential treatment facilities. Journal of Disability Policy Studies, 16(4), 202–208. https://doi.org/10.1177/10442073060160040101
National Institute for Health and Care Excellence (NICE) (2015). Challenging behaviour and learning disabilities: Prevention and interventions for people with learning disabilities whose behaviour challenges. http://www.nice.org.uk/guidance/ng11 [accessed 29th November 2022].
Nijs, S., Taminiau, E. F., Frielink, N., & Embregts, P. J. (2019). Stakeholders’ perspectives on how to improve the support for persons with an intellectual disability and challenging behaviors: A concept mapping study. International Journal of Developmental Disabilities, 0(0), 1–10. https://doi.org/10.1080/20473869.2019.1690859
Nunno, M. A., McCabe, L. A., Izzo, C. V., Smith, E. G., Sellers, D. E., & Holden, M. J. (2022). A 26-year of restraint fatalities among children and adolescents in the United States: A failure of organizational structures and processes. Child & Youth Care Forum, 51(3), 661–680. https://doi.org/10.1007/s10566-021-09646-w
O’Donoghue, E., Pogge, D., & Harvey, P. (2020). The impact of intellectual disability and Autism Spectrum Disorder on restraint and seclusion in pre-adolescent psychiatric inpatients. Journal of Mental Health Research in Intellectual Disabilities, 13(2), 86–109. https://doi.org/10.1080/19315864.2020.1750742
O’Dwyer, C., McVilly, K. R., & Webber, L. (2017). The impact of positive behavioural support training on staff and the people they support. International Journal of Positive Behavioural Support, 7(2), 13–23.
Pfadenhaur, L. M., Gerhardus, A., Mozygemba, K., Lysdahl, K. B., Booth, A., Hofmann, B., Wahlster, P., Polus, S., Burns, J., Brereton, L., & Rehfuess, E. (2017). Making sense of complexity in context and implementation: The context and implementation of complex interventions (CICI) framework. Implementation Science, 12(1), 21–21. https://doi.org/10.1186/s130-017-0552-5
Poppes, P., van der Putton, A. J. J., & Vlaskamp, C. (2010). Frequency and severity of challenging behaviour in people with profound intellectual and multiple disabilities. Research in Developmental Disabilities, 31(6), 1269–1275. https://doi.org/10.1016/j.ridd.2010.07.017
Prior, D., Win, S., Hassiotis, A., Hall, I., Martiello, M. A., & Ali, A. K. (2023). Behavioural and cognitive-behavioural interventions for outwardly directed aggressive behaviour in people with intellectual disabilities (review). Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD003406.pub5
Royal College of Psychiatry (RCPsych) 2016. Challenging behaviour: a unified approach – Update. Available from college-report-cr144.pdf (rcpsych.ac.uk) [accessed 14th April 2023].
Sanders, K. (2009). The effects of an action plan, staff training, management support and monitoring on restraint use and costs of work-related injuries. Journal of Applied Research in Intellectual Disabilities, 22(2), 216–220. https://doi.org/10.1111/j.1468-3148.2008.00491.x
Scheirs, J., Blok, J., Tolhoek, M., Aouat, F., & Glimmerveen, J. (2012). Client factors as predictors of restraint and seclusion in people with intellectual disability. Journal of Intellectual and Developmental Disability, 37(2), 112–120. https://doi.org/10.3109/13668250.2012.682357
Singh, N. N., Lancioni, G. E., Winton, A. S., Singh, A. N., Atkins, A. D., & Singh, J. (2009). Mindful staff can reduce the use of physical restraints when providing care to individuals with intellectual disabilities. Journal of Applied Research in Intellectual Disabilities, 22(2), 194–202. https://doi.org/10.1111/j.1468-3148.2008.00488.x
Singh, N. N., Lancioni, G. E., Karazsia, B. T., Myers, R. E., Winton, A. S., Latham, A. L., & Nugent, K. (2015). Effects of training staff in MBPBS on the use of physical restraints, staff stress and turnover, staff and peer injuries, and cost-effectiveness in developmental disabilities. Mindfulness, 6(4), 926–937. https://doi.org/10.1007/s12671-014-0369-0
Singh, N. N., Lancioni, G. E., Karazsia, B. T., Chan, J., & Winton, A. S. (2016a). Effectiveness of caregiver training in mindfulness-based positive behaviour support (MBPBS) versus training-as-usual (TAU): A randomised controlled trial. Frontiers in Psychology, 7, 1549. https://doi.org/10.3389/fpsyg.2016.01549
Singh, N. N., Lancioni, G. E., Karazsia, B. T., & Myers, R. E. (2016b). Caregiver training in mindfulness-based positive behaviour supports (MBPBS): Effects on caregivers and adults with intellectual and developmental disabilities. Frontiers in Psychology, 7, 98. https://doi.org/10.3389/fpsyg.2016.00098
Singh, N. N., Lancioni, G. E., Medvedev, O. N., Myers, R. E., Chan, J., McPherson, C. L., Jackman, M., & Kim, E. (2020). Comparative effectiveness of caregiver training in mindfulness-based positive behaviour support (MBPBS) and positive behaviour support (PBS) in a randomised controlled trial. Mindfulness, 11(1), 99–111. https://doi.org/10.1007/s12671-018-0895-2
Smidt, A., Balandin, S., Reed, V., & Sigafoos, J. (2007). A communication training programme for residential staff working with adults with challenging behaviour: Pilot data on intervention effects. Journal of Applied Research in Intellectual Disabilities, 20(1), 16–29. https://doi.org/10.1111/j.1468-3148.2006.00336.x
Sturmey, P. (2018). Reducing restraint in individuals with intellectual disabilities and Autism Spectrum Disorders: A systematic review group interventions. Advances in Neurodevelopmental Disorders, 2(4), 375–390. https://doi.org/10.1007/s41252-018-0088-y
Tomoaia-Cortisel, A., Scammon, D. L., Waitzman, N. J., Cronholm, P. F., Halladay, J. R., & Driscoll, D. L. (2013). Context matters: The experience of 14 research teams in systematically reporting contextual factors important for practice change. Annals of Family Medicine, 11(1), S115–S123. https://doi.org/10.1370/afm.1549
Tyrer, P., Tarabi, S. A., Bassett, P., Liedtka, N., Hall, R., Nagar, J., Imrie, A., & Tyrer, H. (2017). Nidotherapy compared with enhanced care programme approach for adults with aggressive challenging behaviour and intellectual disability (NIDABID): Cluster randomised controlled trial. Journal of Intellectual Disability Research, 61(6), 521–531. https://doi.org/10.1111/jir.12360
United Nations 2006 Human rights. Convention on the rights of persons with disabilities. United Nations Treaty Series. http://www.un.org/disabilities/documents/convention/convoptprot-e.pdf [accessed 29th November 2022].
Vassos, M. V., Nankervis, K., Skerry, T., & Lante, T. (2013). Work engagement and job burnout within the disability support worker population. Research in Developmental Disabilities, 34(11), 3884–3895. https://doi.org/10.1016/j.ridd.2013.08.005
Vassos, M. V., & Carroll, M. F. (2016). Assessing attitudes toward evidence-based practices of workers supporting people with disabilities: A validation of the evidence-based practice attitudes scale. American Journal on Intellectual and Developmental Disabilities, 121(4), 364–378. https://doi.org/10.1352/1944-7558-121.4.364
Vassos, M. V., Nankervis, K., & Chan, J. (2019). Clinical governance climate within disability service organisations from the perspective of allied health professionals. Journal of Policy and Practice in Intellectual Disabilities, 16(1), 67–77. https://doi.org/10.1111/jppi.12281
Webber, L. S., McVilly, K. R., & Chan, J. (2011). Restrictive interventions for people with a disability exhibiting challenging behaviours: Analysis of a population database. Journal of Applied Research in Intellectual Disabilities, 24(6), 495–507. https://doi.org/10.1111/j.1468-3148.2011.00635.x
Webber, L. S., Richardson, B. R., & Lambrick, F. (2014). Individual and organisational factors associated with the use of seclusion in disability services. Journal of Intellectual & Developmental Disability, 39(4), 315–322. https://doi.org/10.3109/13668250.2014.937326
Author information
Authors and Affiliations
Contributions
DG. and M.I. were involved in the development and publication of the protocol, the development of the search strategy, screening and data extraction of studies, and writing and review of the manuscript. A.A. was involved in screening and data extraction of studies and review of final manuscript.
Corresponding author
Ethics declarations
Conflict of Interest
The authors report no conflict of interest.
Additional information
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary information
ESM 1
(DOCX 27 kb)
Rights and permissions
About this article
Cite this article
Iffland, M.A., Gillies, D.M. & Aghaji, A. Organisation-Wide Interventions to Reduce Behaviours of Concern as well as Restrictive Practices with Children or Adults with a Neurodevelopmental Disorder: a Systematic Review. Adv Neurodev Disord 8, 108–121 (2024). https://doi.org/10.1007/s41252-023-00370-1
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s41252-023-00370-1