Cox, Dube and Temple (2015) undertook a review of the research literature regarding the influence of staff training on client challenging behaviour, as there had not, to date, been a systematic review of such articles.

There is a need to understand the relationship between increasing staff skills and knowledge and the challenging behaviour of people with intellectual disability.

Understanding the relationship is important, as Jahr (1998) argued that staff competence in the use of behaviour interventions is critical to improving quality of life for people with intellectual disability. However, there is an apparent assumption in the training literature that challenging behaviour will reduce following training of staff; an overall approach which Stokes and Baer (1977, as cited in MacDonald & McGill, 2013) described as a “train and hope model” (p.,27).

Aims

In their review, Cox, Dube and Temple (2015) aimed to:

1. identify emerging patterns in the research,
2. identify knowledge gaps and
3. make recommendations for future research.

Method

The authors conducted a systematic review of studies published between 1997 and 2013. The criteria for inclusion in their review were that original articles contained the following data:

• changes in client challenging behaviour
• changes in staff outcomes (such as increase in skills and knowledge)
• the studies were conducted in residential service homes or institutions

Excluded from the review were any qualitative studies.

Nineteen studies were identified that met the criteria. Following this, due to the wide range of training approaches that emphasised differing skill sets, the authors categorised training packages into four categories:

• Positive Behaviour Support (n=4)
• Active Support (n=10)
• Crisis prevention and response (n=3)
• Communication training (n=1)

Results

The authors found that there was much variation in: sample size, personnel involved in the training (e.g., direct care staff, management, psychologist), study design and actual time spent in training (1 day, up to several months).

Improvements in client challenging behaviour were reported in 9 of the 19 studies (47%). In six studies, researchers evaluated maintenance of skills and in three of these, the continued lower levels of challenging behaviour were reported at maintenance.

Positive Behaviour Support – in all four studies, researchers reported decreased challenging behaviour, with two including maintenance that was sustained over time.

Active Support – in only two of the 10 studies did researchers report improvements in challenging behaviour

Crisis prevention and response – in none of the three included studies researchers found improvements in challenging behaviour

Communication training – there were initial improvements reported in the one included study, however these were not sustained over time.

Discussion

Cox, Dube and Temple (2015) stated that they were surprised by the small size of their sample, despite a large research literature concerning the topic. During their sampling phase, they found that researchers in the area of staff training in challenging behaviour seldom investigated and reported on the effect on challenging behaviour.

Consequently, they found only a relatively small number of studies that reported this outcome. This is reflective of Stokes and Baer’s “train and hope model” as described earlier.

Strengths and Limitations

There were some weaknesses with Cox, Dube and Temple’s study. They used descriptive statistics rather than calculating inferential statistics (such as through a meta-analysis, for example), as they stated that this method adequately addressed their study objectives.

Unfortunately, this approach has resulted in several difficulties:

1. The strength of the effect of training on challenging behaviour is not able to be determined.
2. Determining whether it was the training which influenced the reductions or whether other factors were perhaps involved is not clear.
3. The extent to which reductions in challenging behaviour occurred is not explicit; the authors simply reported a ‘Yes/No’ regarding reductions in challenging behaviour. Based on the information provided by the authors, the extent of the reductions in challenging behaviour is unknown.

The authors searched for articles published between 1997 and 2013. They indicated the search terms used when searching for relevant articles. Interestingly, they included some specific intervention types (i.e., active support and positive behaviour support), yet other intervention types were not included in the search terms used (e.g., anger management, augmentative and alternative communication).

This approach may have narrowed the scope of the search and some relevant articles may have been excluded. It may also explain why the authors found only one article related to communication training, when there are considerably more studies than that.

The authors also stated that they excluded all qualitative studies. Their methods did not include any statistical analysis of the studies which they did include, therefore, the reasons why qualitative studies were excluded is unclear.

The authors clearly stipulated three aims at the outset of their article, however, they did not delineate these in the discussion section; rather discussion was conflated, with much overlap of themes.

The aims of ‘identifying knowledge gaps’ and ‘recommending future research’ are arguably the same aim. However, in summary, the author’s main conclusions were:

• No researchers assessed generalisation of staff skills
• Indirect assessment and self-developed measures were commonly used, which resulted in non-validated methods being used in many studies
• Future researchers should engage a third party assessment of client behaviour
• Future researchers in this area should measure whether staff are implementing the training properly, as treatment integrity seemed poor. Staff tended to revert to previous practices post-training.
• There is currently a knowledge gap of the effectiveness of training the whole staff group vs select individuals.

Summary

Some of the conclusions made by Cox, Dube and Temple (2015) have been commented on and examined by other authors previously. Some authors have criticized the training research because it is typically situated in clinical environments, removed from the contexts in which it occurs (Campbell, 2007; McNally, 2004). Dempsey and Arthur (2002) argued that there is a disparity between the training and the day to day challenges staff face.

Staff have been required to use their discretion in the application of the methods taught in training when they return to the service setting to work with real people.

Using vignettes in training has been common place, however, the use of vignettes rather than real clients in training may offer some explanation as to why sustained reductions in challenging behaviour have not occurred (Hastings, 2005).

Despite some weaknesses, the evidence presented by Cox, Dube and Temple indicated that overall, the effectiveness of training on challenging behaviour was relatively low.

There is much room for further research in this area, particularly in the use of standardised assessment methods to determine the strength of training effectiveness on challenging behaviour.

Links

Primary paper

Cox, A., Dube, C., Temple, B,. (2015) The influence of staff training on challenging behaviour in individuals with intellectual disability. Journal of Intellectual Disabilities. 19 (1) 69-82. [abstract]

Other references

Campbell, M. (2007). Staff training and challenging behaviour, who needs it? Journal of Intellectual Disabilities, 11(2), 143-156.

Dempsey, I., & Arthur, M. (2002). Support staff in a sample of Australian community-based services for people with a disability: career intentions, personal characteristics and professional development needs. Journal of Intellectual & Developmental Disability, 27(3), 201-214.

Hastings, R. P. (2005). Staff in special education settings and behaviour problems: towards a framework for research and practice. Educational Psychology, 25(2-3), 207-221.

McNally, S. (2004). Plus ca change? Progress achieved in services for people with an intellectual disability in England since the publication of Valuing People. Journal of Learning Disabilities, 8(4), 323-329.

MacDonald, A., & McGill, P. (2013). Outcomes of staff training in Positive Behviour Support: A systematic review. Journal of Developmental and Physical Disability, 25, 17-33.