Implementing the Steps to Effective Problem-solving Program in Group Homes Among Individuals With Intellectual Disabilities and Their Staff

September 14, 2012

Sarah Ailey PhD RN CDDN APHN-BC

Arlene Michaels Miller PhD RN FAAN

Tanya R. Friese MSN RN

Research funded by:

Rush University College of Nursing #31202

Purpose

1.Describe a pilot program implementing a preventive community-based social problem solving program among individuals with ID and their staff

2. Discuss the potential of using the support environment of group homes to assist individuals with ID to maintain and use learned social problem-solving skills.

Background

Aggressive/challenging (problem) behaviors• Destructive, disruptive, socially offensive,

unusual/repetitive, withdrawn/inattentive, and uncooperative behaviors that can be harmful or cause disruption to self and/or others1

• Consequences - loss of programming, psychiatric hospitalizations, incarcerations2-5

• Increase costs• Public health problem for individuals with intellectual

disabilities (ID), their families and supports

Problem behaviors in group homes

• Over 400,000 live in small group homes- Increase >300% over last 20 years6

• 20-25% residents report distress from other residents’ problem behavior7,8

• Residential staff members often do not know how to manage; respond in ways that reinforces problem behaviors9,10

• Punitive methods dangerous and unacceptable to human rights11,12

• Agencies encouraged to promote positive behavior support.13

Social problem-solving• Social problem-solving (SPS)

– cognitive & behavioral processes of solving problems– two independent, interrelated dimensions: attitude & style14

• Deficits increase susceptibility problem behaviors14,15

• Previous research– SPS training in clinical and forensic settings - positive results

on behaviors16-18

– Outcomes better if accompanied by staff19

– Independent action did not increase16

• Needs to translate as preventive interventions in community that might provide support for maintaining and using SPS skills

Group home support system• Group homes setting can

– promote social networks &– contribute to quality and security of life20

• Residential staff members – provide support and assistance with needs21 – Some report relationships with residents as a

source of satisfaction, view jobs as a calling21

• Need to improve support system of group homes and reduce problem behaviors

Steps to Effective Problem-solving

• Based on research-based SPS program14 • Developed for group home setting using multiple

sequential methods22

– input from supervisory staff responsible for behavioral programming for individuals with ID

– cognitive interviews among individuals with ID and residential staff members

– Pilot of program in two group homes– Follow up interviews individuals with ID & residential

staff

STEPS• Number of modules reduced to 6 (12 in original)22

– positive attitude toward problems, – situations likely to lead to problem behaviors– rational problem solving behaviors including defining problems, developing

alternative solutions, and predicting consequences of rational responses vs. problem behaviors.

• Training in stopping, slowing down, thinking and acting integral part of the program23

• Interactive exercises, role-play, card sorts, practice exercises, electronic media components

• Didactic material minimized• Materials to develop group environment • Advice on where and when obtained22

STEPSSTEPS is designed to systematically build on

the ongoing relationship between residential staff and individuals with ID in the group homes and the relationships between the residents as a means of assisting individuals with ID to maintain and use learned social problem-solving skills.

STEPS Pilot study

The purpose of this study was to 1) assess the feasibility of delivering

STEPS as a preventive intervention to reduce problem behaviors in group homes

2) evaluate the initial efficacy of STEPS.

A s s e s s m e n t I n t e r v e n t i o n O u t c o m e s

B a s e l i n e 0 - 1 2 W e e k s W e e k s 1 2 , 2 4

F i g u r e 1 : S t e p s t o E f f e c t i v e P r o b l e m - S o l v i n g ( S T E P S ) F r a m e w o r k

A g g r e s s i v e / C h a l l e n g i n g B e h a v i o r

D e t e r m i n a n t s

B a c k g r o u n d – P a s t a n d C u r r e n t

D e m o g r a p h i c

L i f e e v e n t s

E n v i r o n m e n t

C u r r e n t h e a l t h

• D e p r e s s i v e s y m p t o m s

• M e d i c a t i o n m a n a g e m e n t

S P S

• A t t i t u d e

P o s i t iv e

N e g a t iv e

• S t y le

I m p u l s i v e

R a t io n a l

S T E P S

T r a i n i n g in S P S s k i ll s

t o I n c r e a s e a t t i t u d e

• P o s it i v e a t t i t u d e

• R a t i o n a l s t y le

P a r t i c i p a n t

O u t c o m e s

S P S s k il l s

• A t t i t u d e

• S t y le

A / C B S

S u p p o r t E n v i r o n m e n t f o r S P S

• R e s i d e n t i a l s t a f f • G r o u p S P S

S P S • G r o u p c o h e s i v e n e s s

STEPS Framework

STEPS Framework

• Based on – Interaction Model of Client Health Behavior24

– Relational/Social Problem-Solving Model of Stress14

• Grounded in philosophical construct of human agency25

STEPS FrameworkExamines explanatory relationships among• determinants of problem behaviors

– Depression– Life events– Age– Gender

• intervention strategies• support environment for SPS skills

– Residential staff SPS– Group problem-solving– Cohesiveness

• outcomes of SPS skills and problem behaviors.

Design: Subjects

• Group home level– two group homes were recruited through one

agency in a Midwestern metropolitan area – inclusion criteria - homes with at least one

incident report for behaviors per month over at least three months

– 33% of the residents in the homes had incident reports.

Design: Subjects• Individual level • Individuals with ID

– Of 14 residents in two homes • 12 agreed to participate; of these, • 9 required consent of a legal guardian

• Residential staff – Six residential staff signed consents

• four actually participated, two staff in each home. • One staff participant left employ of agency midway

Background characteristics

Individuals with ID• 7 men, 5 women• 25% minorities • Mean age 36.6 (SD 10.5)• On average, 5 life events (range 0-9)26

• Mean depression score (GDS-LD) 10.5 (SD 7.9)27

Residential staff• 4 women • 50% minorities.

Feasibility

• Attendance - Average Number sessions attended

• Satisfaction- after each module, end of program

• Fidelity - Breitenstein’s Fidelity Checklist29- from coded audiotapes of sessions– Adherence

– Competence

• Participation in the intervention - coded audiotapes of sessions

Attendance• Individuals with ID attended 70%

– men went to another location for 3 modules

• Residential staff attended 67% – residential staff members were not all scheduled

to work the days of the intervention.

Satisfaction• Satisfaction with sessions high to very high

– individuals with ID - 91%– residential staff - 87%

• At final evaluation, high to very high – >80% both groups– Individuals with ID wanted more of program– Residential staff helpful aspects

• training in breaking down problems • getting to know how individuals with ID relate to each other

FidelityCompetence• Leaders demonstrated over 75% of the time• Skills included:

– effectively responding when participants resistant

– maintaining good pace for group discussion – helping anticipate challenges in using new skills

FidelityAdherence • Leader was scored over 90% for most

sessions.• Strengths included:

– communicating in respectful, positive, and non-judgmental manner.

– non-judgemental about discussed behavioral issues such as throwing items and fighting

– positive behaviors encouraged – facilitated discussion alternatives to negative

behaviors.

ParticipationAudiotapes of sessions coded for:

• Participant discussion during the sessions– key concepts discussed

– number of sessions each concept discussed

– mean times concepts discussed each session

Table - participationTable 2: Participation in discussion of social problem-solving concepts

Concept Component Number of session

concept and concept

component discussed

Mean time discussed in

those sessions

Stop and slow down 10 6.1

Examples of impulsive

behavior

5 2.8

Feelings they have as

antecedent to impulsive

behavior

8 3.9

Examples avoidant

behavior

2 2

Define Big or small 7 4.4

Whose is it 6 2.7

Important or not 2

Do something about it 6

Alternative solutions 7

Predict 6 4.7

Gave examples of using

skills

5 2.8

Examples of problems 8 8.9

Initial efficacy• Support environment for SPS (mediating

factor in conceptual framework)– Residential staff SPS

• Social Problem-solving Inventory-Revised (self report)30

– Group level SPS • Group-level problem-solving scales of Iowa Family

Interaction scales (IFIRS)31

– Cohesiveness• Cohesiveness subscale Group Environment Scale22

Support environment for SPSResidential staff SPS• Improvement Effect size of =.62 • Mean scores increased from 69.7 (SD 7.25) to 74.0

(SD 6.6)

Group SPS• Improvement in group-level problem solving was =.78 (pre and post-intervention). Scores increased

from 15 (SD 1.4) to 17.5 (SD 4.9)

Cohesiveness• Effect size for improvement in cohesiveness was=1.43 (first session to last session). Scores

increased from 28.5 (SD .71) to 30.0 (SD 1.4).

Outcomes: SPS skills individuals with

ID• Individual-level Problem-solving Scales of

IFIRS- Coded videotape (outside evaluator) – Effect size for improvement in was =.55. Mean

score on the Problem-solving Scales increased from 8.8 (SD 4.8) to 11.7 (SD 5.8)31

• Problem-solving Task17-coded audiotape (self-report)– Effect size for improvement on Problem-solving

was =.59. Mean scores increased from 42.4 (28.1) to 59.4 (SD 29.1).

Outcomes: Behaviors individuals with ID

• Dyadic Interaction Scales of IFIRS (negative behaviors)31

Coded videotape (outside evaluator) – behaviors include: hostility, verbal attack, physical

attack, contempt, angry coercion, hostile escalation, reciprocal hostility, dominance, lecturing/moralizing, interrogation, denial.

– The effect size for decrease in problem behaviors was =1.32 for individuals with ID. Scores decreased - mean 17.9 (SD 4.7) to12.5 (SD3.5)

Conclusion

• STEPS pilot showed– reasonable attendance and satisfaction with the

program – Intervention fidelity – participants discussed key concepts

• As in the previous research, effect sizes – indicated improvement in social problem-solving

and behaviors for participants with ID.

Conclusion• Important incremental advance

– addressed support environment for social problem-solving

– Despite small sample size, effect sizes indicate support environment might be improved with interventions

• A larger study is necessary– address whether improvements in support

environment can assist individuals with ID to maintain and use learned SPS skills

– whether approach prevents problem behavior – can costs of problem behaviors be reduced

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