Behaviour: Debriefing and Post-Incident Support

When things go wrong.

I truly wish that I was able to get everything right for all the children I am educating. To be placed at the school I work at usually means being excluded or having demonstrated a need that cannot be met through other provisions. At times this manifests through incidents of behaviour that challenges us to ask “What are these actions telling us?”. You can call it challenging behaviour but these events really demonstrate is a highly anxious,frustrated or traumatic reaction to stress, Autistic children are not any more prone to behavioural incidents than other children so we need to look deeper if our interactions or environment is leading to issues.

_What are these actions telling us__ debriefing challenging behaviour.jpg

It is our job as specialist teachers to figure out what went wrong and what we can do to support that child. This may be changing environments, our interactions, communication systems. What we don’t want is blame, shame and judgements of decisions made under stressful circumstances – safeguarding, legal and ethical consideration take precedent however.. Too often after things went wrong we would just pick up and carry on. Ethically and morally this is not good enough we need to recognise that things didn’t go as planned and we owe it to our children to acknowledge we had a role in that. So my behaviour support team began a project to develop a system that can be used to debrief students and staff following more severe incidents that will undoubtedly have had a negative impact on the child or staff. Below I am going to share with you an approach that you may find useful (even if you adapt it). There are things that would be beneficial to implement alongside this:

  • Trauma and attachment Training.
  • A Wellbeing policy.
  • A flexible and supportive behaviour policy
  • A review of behaviour support plans to ensure they are accessible.
  • A communication profile for each child i.e PECS, Symbol support etc.
  • A DisDat – Distress passport
  • Make time to do this – you will save time and energy in the long term.

Different approaches are needed for each child according to their primary communication system. Those undertaking a debriefing need to have access to a range of resources and a good understanding of the student’s needs, more than that they need an insight into the interaction style and preferences of each child. You can’t bluff this and if this is seen as a tick-box exercise everyone is wasting their time. We developed a resource pack and distributed these so every area had one, both classes and residential areas. Staff have been asked to adapt these as they use them and feedback. Staff debriefing was initially conducted by the school’s behaviour lead but it was felt that being a senior leader this may not have facilitated open discussion so a group of staff volunteered to undertake these as well.

The approach we take must not be to apportion blame but to seek to repair relationships, support staff and gain a greater understanding of the actions and reactions of all concerned. This is important to ensure discussions are honest and open and staff do not fear disciplinary action resulting from perceived mistakes. If serious errors in judgement or potential safeguarding issues are reported further reporting will be required.

Debriefing systems have two elements that run in parallel.

  • It can affect change in practice and procedures enhancing outcomes for our students through providing an expedient training and feedback opportunity.
  • It can provide emotional support to both students and staff, if the experience of a restrictive practice or incident of challenging  was traumatic for either or both (Jones and Kroese 2006 cited in Sturmey 2015).

Utilising these systems would benefit any school/organisation/community. This post has three sections relating to debriefing. Some of the research used may have a clinical element to it and it would be great to enable staff to be trained in trauma therapy. If a student or member of staff appears to be suffering from severe levels of stress or anxiety following an incident they should be supported to access additional specialist help. This document will provide guidance on possible approaches that could be used for post incident action.

  1. Student Debriefing
  2. Staff Debriefing
  3. Organisational Approach

Debriefing will seek to answer these questions:

Who was involved?
What happened?
Where did it happen?
Why did it happen?
What did we learn?
(Cook et al., 2002; Hardenstine, 2001)

1. Student Debriefing

Communication needs

Enhancing communication for and with our children should be the primary role of any educational setting. Providing the skills and methods to reflect on an incident poses a number of challenges in practice particularly for those individuals with a severe learning disability. There needs to be an acceptance from external agencies that any student debriefing in practice faces a range of challenges faced in translating complex Information (Kruger and Northway 2017).

Very limited research is available on debriefing Autistic children following incidents. We  therefore developed our own system and maintain a record of all debriefs. These will are quality assured by senior staff. The mental health services Code of practice for the mental health act (DoH 2015) states that a post incident review should be should be undertaken following restrictive practice to help patients understand what has happened. It is felt that some of our children would benefit from this explanation. It will be down to staff discretion whether a debrief is appropriate as it is felt that bringing up an incident may illicit an anxiety or negative response.

Resource Development

Do to the nature and complexity of the challenges faced by our students each will require an individualised approach to how  post incident actions are managed by the staff team. A number of resources have been developed to use with students to help them understand the situation.

Challenging behaviour debrief symbol version.jpg

It is highly recommended that staff adapt these as required to match the skill level of the individual. Staff will be encouraged to share these adapted versions and be expected to trial different methods to engage the students in this process.

student debrief symbol Widgit.jpg

Download the Resource pack here (You will need Inprint 3 for some of the debriefing forms)

2. Staff debriefing.

Staff stress may be linked to the behaviours displayed or be influenced more by the working environment itself.  (Thomas and Rose 2007). The nature and type of incident will affect the emotional response of staff (Hastings 2005). This will in turn impact of that person’s ability to implement the PBS plan effectively. All behaviour is really an outcome of an interaction either with the environment, an internal driver, or another person.

“When the cycle of negative staff-individual interactions is broken, more positive outcomes arise” Nirbhay N. Singh (2006)

Hastings (2005) talks about the impact of challenging behaviour as taking resources (of energy) from the people supporting the individual. This creates a negative feedback loop that can be so destructive for the child’s self esteem and stress levels (Lecavalier 2006). The more stress staff are under then less effective they are at implement strategies the child relies on.  Hastings (2010) shares the casual relationship between staff and child behaviours. He describes it as “Staff behaviour affects behaviour problems, and behaviour problems affect staff behaviour.”.

It would be appropriate to say that a process must exist for interrupting this cycle both to ensure incidents of challenging behaviour reduce and to improve student and staff wellbeing. This should have organisational benefits in improved staff retention and reduction of sickness/injury. Primarily though we would be expecting the amount of positive interactions experienced by the children should increase ultimately leading to improved quality of life outcomes, which in my view is the whole purpose of education.

By involving the staff dealing with the situations in finding possible solutions we hope to gain additional buy in and support for the plans created to support our students.

Impact of Serious Incidents

Matthews 1998 suggests that 80% of staff will experience one or more symptoms of PTSD immediately following an “assault” with 30% continuing to experience these up to 6 weeks afterwards. At times our students may experience aggression targeted towards themselves by other students so their reactions may be similar but within the context of reduced understanding and training.

These symptoms may present as:

  • Intrusive thoughts
  • Re-experiencing the incident
  • Numbing
  • Avoidant behaviours
  • Hyperalertness

The resulting stress has been linked to reduced cognitive, emotional and behavioural performance (Mitchell and Dyregov 1993 cited, in Matthews 1998). If we can identify these elements we can start to target or suggest appropriate support strategies and resources.

The Debrief.

Taking the two factors – behaviour and workplace environment or ethos and providing a system for reviewing them and providing support should increase staff wellbeing and thus the effectiveness of any strategies used. The level and adequacy of managerial support has been identified by two studies to have an impact of the maintenance of staff wellbeing. If the debrief provides the communication/contact point between staff and management the construction of the process needs careful thought. Vassos et al (2013) suggested that a positive impact on staff can be achieved by providing specialist support as well as feedback and clarity of role. Enhancing the training of PBS techniques has been shown by Lowe et al (2007) to boost staff willingness to engage with proactive strategies – In most cases this will be outlined in the Behaviour Support Plan or Behaviour Intervention Plan. It is these proactive strategies we must develop to be as effective as possible. PBS or otherwise make sure the environment minimises or removes all aversive stimuli.

Positive and proactive care (Department of health 2014) states that debriefing is essential and especially that it should involve an element of learning and emotional support for staff. This is supported by the Care councils for Wales’s guidance Positive Practice: Reducing Restrictive Practices in social Care.  This states that debriefing should occur immediately following an incident – or shortly after. I would aim for a debrief to be completed within 24 hours of an incident. If it is felt necessary a second stage debrief should be completed within 5 working days.

the factor that the member of staff can have most immediate influence over is their own role in the interaction.jpg

A debriefing should provide the opportunity to support the staff member and to inform change within any setting, with the aim of reducing the likelihood of the situation recurring. Baker (2017) states that too often these aims are seen as being met by asking the staff to reflect on what they did wrong. Which then negates any positive message of staff support. However part of the role of the debrief could be to try and ensure the situation does not reoccur, the factor that the member of staff can have most immediate influence over is their own role in the interaction or incident. Hastings (2010) states that changing staff practice can have a significant positive effect on outcomes for the people they work with, and that this is the priority.

Concern has been raised about the possibility that the staff may experience an increase in symptoms or even denial following the debriefing process. There is also little research on the cumulative element of working in a  challenging environment daily. It is clear that each individual will respond to stress differently with some requiring no additional input. Develly and Cotton (2004) suggest that this approach is effective when the culture and relationships around the individual is positive. So at times an informal “chat” or recognition from senior staff may be all that is needed. Here is a possible staff debriefing form you may wish to use for a formal session.

This led us onto the question whether the debrief should be a multifunction tool or specifically designed to meet one of the parallel concerns. Following a discussion it was felt that the debriefing could achieve both aims with a reflective element and a learning focus that seeks to inform and improve the behaviour support plan. Here is a suggested layout for an easy to read a simple plan that all stakeholders should have input into.

suggested BSP layout challenging behaviour support plan.jpg

What should be included in the Debrief?

I have based these suggestions on the CISD (Critical incident stress management) programme, An intervention that can be effective in identifying staff needs and directing staff to additional support if required (Mitchell 2004). Evidence for the effectiveness of which is limited in the field of intellectual disability with only one research study (Matthews 1998). It has also been suggested that it is not used as a stand alone tool. Therefore this will sit within a framework and system of support. (Pack 2017). I have outlined how this process may tie in with our system.

  •         Detailed disclosure of facts
  •          This is accomplished through our current and continually reviewed incident data collection.
  •         Elicitation of thoughts and emotional reactions
  •          This is captured through a face to face discussion initially led by teacher/team leader
  •         Coping strategies on coping with traumatic stress.
  •         This would take the form of offering staff access to the supportline.
  •         Visible leadership support and ongoing review.
  •         Troubleshooting and planning for the future
  •          A review of the BSP
  •          Additional information gathering and analysis.

 

Developing a best practice protocol

What training should debriefers have?

The debriefing model should be developed specifically for those working in the context the incident occurs. A Staff’s personal trauma history will impact reactions to further trauma (Horn 2002 in Baker 2017), this information may not be available to those conducting the debriefing so consideration to this possibility should be given. Bisson (2007) states that prevalence of symptoms of traumatic emotions, memories and stress decrease over time. So it may be that the initial debriefing should not be done immediately but within 48 hours to allow emotions to stabilise. Debriefings must be Non judgemental (singh et al 2006). Any positive elements the work provides primarily through relationships, warmth etc (Hastings 2010) may moderate work stress so the debriefing is not the only route that can be explored for looking at staff wellbeing and perception of how much they enjoy their job. .

Feedback to PBS trainers about staff attitude to behaviour support (Hastings and Brown 2002 cited in Hastings (2010) may be useful when determining the focus of future training needs.

3. Organisational Impact

Many factors at play within an organization’s culture and policies can impact on staff wellbeing and their response to challenging behaviour. Research from Hastings (1995 Cited in hastings 2010) suggests it is the more informal aspects of an organisation’s culture that can have the most powerful effect on staff behaviour. These include, working relationships within staff groups.

“The consequences for challenging behaviour are mostly mediated by others : attention, termination of demands, the control of tangible reinforcement and punishment. Even stereotypy may only occur because other people have left an individual alone with nothing to do.”  & “researchers and practitioners would agree that there are times when programmes are simply not followed by staff”

(Hastings and Remington 1994).

Behaviour problems do not occur in isolation and there is often a discrepancy between theoretical models and application of strategies by staff teams. Part of the role of the leadership in any organisation will be to ensure consistency of approach across day and residential settings and ensuring behaviour support plans are followed. Through debriefing we hope to ensure these reflect current practice and the strategies outlined within them are effective. The process of debriefing will allow us to refer back to the live behavior support plan and cross reference the strategies outlined with those used during the incident.

Studies suggest that challenging behaviours are aversive to staff – well staff are challenged I suppose. Therefore when delivering staff training it may be valuable to teach staff skills that would enable them to deal with this part of their work. Examples of this could include teaching a range of coping skills, involving self-instruction of their behaviour, problem-solving skills, and relaxation techniques. Preliminary evaluation suggested that staff report less anger after such training, and use emergency restraint procedures much less (Hall & Oliver 1992). Having bespoke training packages delivered and informed by debriefing may help us apply this.

Staff often feel judged when their children display negative behaviours. External training is not valued by staff and a priority is placed within teams of ensuring safety of colleagues above the behaviour policy or support plan. Hastings (2010) suggests that training should include stress identification and coping mechanisms for staff be included. Legally employers are required to conduct risk assessments and act prudently to ensure their employees’ safety. “This includes identifying and minimizing employee risks from violence and aggression from clients” (Sturmey 2015).

To meet our responsibilities as an employer we must:

  • have a clear policy,
  • a risk assessment system,
  • clear procedures to specify what actions to take in risk situations,
  • provide appropriate training,
  • provide a safe work environment,
  • provide staff support relating to violence,
  • ensure that the procedures are workable and review them,
  • provide debriefing after an incident.

Debriefing and Post-Incident Support Legal requirementspinterest graphic.jpg

 

Summary: Lets work together to get it right next time.

The more input, knowledge and understanding of the child that informs the plan the more likely it is to succeed. So once you’ve done a debrief feed the child’s feelings into the plan. Be flexible. If you don’t know something ask the child, or the parents I’m sure they will be able to offer insight. Sit down as a team and be honest your children will display behaviours as a reaction to something – reflect on how you can prevent that happening again. Physical interventions, injuries, restrictive practice of any kind is traumatic and can have long lasting consequences we should do all we can to prevent these happening.

 

References

Baker, P.A. 2017. Attending to debriefing as post-incident support of care staff in intellectual disability challenging behaviour services: An exploratory study. International Journal of Positive Behavioural Support, 7 (1). pp. 38-44. ISSN 2047-0924.

Bisson, J. & Andrew, M., 2005. Psychological treatment of post-traumatic stress disorder (PTSD) Jonathan Bisson, ed. Cochrane Database of Systematic Reviews. Available at: http://dx.doi.org/10.1002/14651858.cd003388.pub2.

Hall, S. & Oliver, C. (1992). Differential effects of severe self-injurious behaviour on the behaviour of others. Behavioural Psychotherapy, 20, 355-366.

Hastings, R.P. 2010. Staff in special education settings and behaviour problems: towards a framework for research and practice, Educational Psychology, 25:2-3, 207-221, DOI: 10.1080/0144341042000301166

Hastings, R, P.. 2010. Support staff working in intellectual disability services: The importance of relationships and positive experiences. Journal of Intellectual and Developmental Disability 35:3, pages 207-210.

Kelly, Á. Carey, McCarthy & Coyle. 2007. Challenging behaviour: principals’ experience of stress and perception of the effects of challenging behaviour on staff in special schools in Ireland, European Journal of Special Needs Education, 22:2, 161-181,

Kruger, B. & Northway, R., 2017. An exploratory study of Behavioural Specialist experiences of involving service users in the development of their positive behavioural support plans. Journal of Intellectual Disabilities.

Lambrechts, G., Kuppens, S. & Maes, B., 2009. Staff variables associated with the challenging behaviour of clients with severe or profound intellectual disabilities. Journal of Intellectual Disability Research, 53(7), pp.620–632.

LeBel, J., Stromberg, N., Duckworth, K., Kerzner, J., Goldstein, R., Weeks, M., & Sudders, M., et al. 2004. Child and adolescent inpatient restraint reduction

Lecavalier, L. , Leone, S. and Wiltz, J. 2006, The impact of behaviour problems on caregiver stress in young people with autism spectrum disorders. Journal of Intellectual Disability Research, 50: 172-183. doi:10.1111/j.1365-2788.2005.00732.x

Lowe, K. , Allen, D. , Jones, E. , Brophy, S. , Moore, K. and James, W. 2007, Challenging behaviours: prevalence and topographies. Journal of Intellectual Disability Research, 51: 625-636

Matthews, L.R., 1998. Effect of Staff Debriefing on Posttraumatic Stress Symptoms After Assaults by Community Housing Residents. Psychiatric Services, 49(2), pp.207–212. Available at: http://dx.doi.org/10.1176/ps.49.2.207.

Mitchell, J.T., 2004. A Response to the Devilly and Cotton article, “Psychological Debriefing and the Workplace ….” Australian Psychologist, 39(1), pp.24–28.

Nirbhay N. Singh a,*, Giulio E. Lancioni b, Alan S.W. Winton c, W. John Curtis d, Robert G. Wahler e, Mohamed Sabaawi f,Singh a, Kristen McAleavey g, 2006. Mindful staff increase learning and reduce aggression in adults with developmental disabilities. Research in Developmental Disabilities 27

Pack, M. 2017 Self-help for trauma therapists: A practitioner’s guide. Routledge: New York, NY

Sturmey, P., 2015. Reducing Restraint and Restrictive Behavior Management Practices. Autism and Child Psychopathology Series. Available at: http://dx.doi.org/10.1007/978-3-319-17569-0.

Van Dam, C. Nijhof. Veerman. Engels. Scholte.  & Delsing M. 2011. Group Care Worker Behavior and Adolescents’ Internalizing and Externalizing Problems in Compulsory Residential Care, Residential Treatment for Children & Youth, 28:3, 232-25.

Australian Guidelines for the Treatment of Acute Stress Disorder and Posttraumatic Stress Disorder Available online at: http://phoenixaustralia.org/wp-content/uploads/2015/03/Phoenix-ASD-PTSD-Guidelines-Summary.pdf

Debriefing and Post-Incident Support pinterest graphic.jpg

 

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