Literature review on intervention with challenging behaviour in children and youth with developmental disabilities
This report, by Luanna Meyer and Ian Evans, summarises the processes, approach, and findings of a review of the literature and knowledge base regarding severe challenging behaviour in children and young people with developmental disabilities. The review is focussed on effective educational and support services for children and youth whose behavioural challenges accompany a diagnosis of intellectual disability, developmental delay, severe learning difficulties, severe traumatic brain injury, and/or autistic spectrum disorder.
Author(s): Luanna Meyer & Ian Evans
Date Published: December 2006
This report summarises the processes, approach, and findings of a review of the literature and knowledge base regarding severe challenging behaviour in children and young people with developmental disabilities. Our review is focussed on effective educational and support services for children and youth whose behavioural challenges accompany a diagnosis of intellectual disability, developmental delay, severe learning difficulties, severe traumatic brain injury, and/or autistic spectrum disorder.
The review follows well-established procedures, including an extensive search of published research in journals and monographs for intervention studies, theoretical contributions, and previous reviews of the literature covering work carried out in New Zealand and the extensive body of work available internationally. Reports andpublications were identified through searches of on-line databases, 22 majorinternational refereed journals in the field for the years 1988-2005, major books, and e-mail contact with leading researchers to locate information on research still in
press. In all, information regarding more than 1,000 journal articles resulted in sourcing and developing an EndNote dataset of nearly 700 reports in order to identify those that met required criteria for different components of the review.
Our review is multi-method, involving both quantitative and qualitative analyses. Included in the review is a meta-analysis of research reports meeting rigorous criteria for this component, and a more traditional review of the broader literature including clinical judgements regarding evidence-based best practices in interventions with challenging behaviour. Our approach and findings were critiqued by external expert reviewers as well as by key personnel in the Ministry of Education.
The final report analyses empirically the evidence from systematic intervention research regarding the relative effectiveness of interventions implemented to achieve desired behavioural outcomes for children, young persons, and their families. We have incorporated available evidence-based New Zealand research and education sector interventions, particularly those with a bicultural focus and designed to meet the needs of Māori students and their families.
The review report includes details of findings from the meta-analysis of effective interventions as well as highlights exemplars of approaches appropriate for intervening during the early childhood, middle childhood, and adolescent years for children and youth with developmental disabilities and challenging behaviour. A summary of evidence-based best practices includes discussion of criteria for intervention decision-making, standards for evaluating interventions, and contextual and cultural variables critical for the design of appropriate and effective strategies.
Critical features of effective interventions are summarised and professional development needs highlighted.
A Glossary of Key Terms and Abbreviations is provided in Appendix A to aid communication with readers who will approach the review from their different methodological and theoretical perspectives.
Best practices in behavioural intervention
- A functional analysis of the purposes of behaviour for the child is incorporated into intervention planning for the majority of research reports in the published
- Positive interventions implemented in a variety of environments now predominate in the published literature in comparison to reliance on restraints, aversives, or other intrusive approaches more commonly reported in clinical research published prior to 1990.
- The best outcomes appear to occur when treatments are not driven bymedication, aversives, intrusiveness, and use of restraints. In addition to producing the best results, positive interventions lend themselves to sensitive, ethical, and socially responsible service delivery.
- Multi-component interventions are both recommended and increasingly common in the published literature across all categories of challenging behaviour.
- The published literature continues to favour programmes tailored to individual child needs rather than diagnosis or age per se, but increasingly incorporates attention to the child’s developmental level as well as the contextual fit of an intervention with the child’s environment and culture.
- In Aotearoa New Zealand it is essential that there be involvement andcollaboration with whānau whānui, respectful of the mana and contributions of community to intervention design, and evidence is promising that the incorporation of culturally appropriate principles and practices will have a positive impact on child and family outcomes.
Evidence of intervention effectiveness
- Self-injurious, stereotypic, socially inappropriate, and destructive behaviour responded well to behavioural treatments, while the results for aggressive and disruptive behaviour were less successful.
A child’s primary or secondary diagnosis did not moderate outcomes; that is, the child’s “syndrome” (and the cluster of behaviours associated with that syndrome) is of less significance to the success of an intervention than the nature of the challenging behaviour.
- Our meta-analysis results reveal that an effective intervention is likely to involve peers, be organised by a professional or teacher, and can be carried out in a number of controlled contexts (residential/home, school, treatment room), whereas lower effect sizes occurred with wider settings in the presence of complex “real life” events. Involving family members and siblings in the intervention did not necessarily result in significantly better outcomes. However, given the short time period during which published interventions monitored outcomes, we don’t know the extent to which positive results achieved in a controlled setting will generalise and maintain to the child’s natural environment.
- Theory would predict that positive results achieved in natural settings are more likely to maintain, while those achieved under relatively artificial, controlled settings will not maintain without the application of another intervention phase to generalise those results, but further research is needed to investigate this issue.
- Combination treatments incorporating systems change, and single treatments without system change, both produced satisfactory outcomes. All combinations were effective in maintaining behaviour reductions, consistently produced better effects than single treatments, and performed well in modifying challenging behaviour. Single treatments in conjunction with systems change were best at maintaining a zero rate of behaviour.
- Skills replacement training outperformed other single treatments (e.g., modifying antecedents or consequences) and performed best in combination with systems change. Further, skills replacement training was equally effective across all ages and diagnoses.
- There is no evidence of difference in treatment responsiveness for children diagnosed as Autistic/ASD in comparison to children with other diagnoses, with the exception of a slight effect for the inclusion of an antecedent treatment component for children with ASD in comparison to other children. Overall, skills replacement training significantly outperforms all other treatment approaches for children with autism, as it does for children with other diagnoses.
- A well-targeted, carefully applied, and time-limited intervention, conducted within or close to the resources readily available to the treatment provider, is likely to be more useful and effective than alternatives requiring extraordinary resources, supports and extended durations of treatment.
Recommended Levels of Behavioural Support
Level 1 Behavioural Support:
Placement in integrated school and community environments with a positive behaviour support programme that makes possible access to participation with peers in a normalised if partially restrictive range of school and community activities leading to meaningful educational and social outcomes.
The majority of students with significant challenging behaviour can be
accommodated within safe early childhood centres/services and schools, provided that support and specialised training services are available to teachers and caregivers within an inclusive educational model.
Level 2 Behavioural Support:
Placement in a more restrictive school setting with a positive behaviour support programme that facilitates at least some access to typical educational/community settings and activities plus participation with nondisabled peers.
A minority of children in the middle years and the majority of secondary age youth with severe challenging behaviours may require this level of service at varying, limited periods of time. Where a more restrictive placement is needed, there must be ongoing access to typical schools available throughout the programme, with the goal of an inclusive educational placement signifying successful intervention.
Level 3 Behavioural Support:
Level 1 or Level 2 plus wraparound child-centred services and/or parent training outside the range of the normal school day and/or school year to support families.
Wraparound support and training services should be available to all families with a child aged birth to 8 years who has severe challenging behaviour, at a level appropriate for caregiver capacity and preferences. Wraparound community-based services for families with older children should also be provided on an as-needed basis, because of the severe needs at secondary ages if earlier interventions have not successfully reduced serious challenging behaviour. Without wraparound community-based services, families and typical school environments are unlikely to be able to accommodate the level of risk to safety of the child and others.
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