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When supporting older adults with learning disabilities and behaviours of concern, we recognise the behaviour being presented is a form of communication; an individual who is trying to communicate how they are feeling or that they have an unmet need. Once we can better understand functions of behaviours and associated drivers, we can put plans in place to support them.
To enable effective positive behaviour support plans to be implemented, one of the elements we don’t always consider is the experiences individuals in our care bring with them from childhood into adulthood, and how these experiences could be influencing the behaviours of concern being presented as adults.
Considering relational trauma
We need to consider the impact some of these past experiences have had on individuals, and if psychological trauma has been a part of those experiences, in particular relational trauma.
Relational trauma would suggest that the individual has experienced difficult things in relation to another person. It is important to remember that not all individuals who have experienced relational trauma throughout their lives will be traumatised and the experiences will be different from one person to the next. These potentially traumatic experiences can be significantly increased for someone with a learning disability as the individual may not fully understand why the experience or trauma is happening, if it will happen again, and if so, when.
The impact of early relationships
The relationships around us are important. They can make us feel safe and help us to learn about ourselves and others. Children learn how to receive care by prompting adults around them to respond to cues, such as crying or holding arms out, which promotes physical closeness and helps safe and fulfilling relationships to flourish, otherwise referred to as attachment.
The difficulties some primary caregivers of children with disabilities come up against is finding it difficult or confusing to respond to cues fast enough or miss them entirely, meaning secure attachments are more difficult to achieve in early childhood. Examples of these may include:
- Difficulty connecting due to speech, language and communication needs.
- Abuse or neglect in the home.
- Separation due to regular hospital admissions.
- Trauma in the family.
- Additional needs from other family members.
- Adults trying to come to terms with feelings associated with the “loss of the healthy child”.
If early relationships made an individual feel unsafe, their bodies will most likely be primed to respond to ongoing or existing relationships as though they could be threatening later in life. Individuals who have experienced relational trauma can regularly be in the “threat mode” of the brain or have this system triggered very easily.
Common behaviours of concern
We know there are some common behaviours of concern that are linked to attachment difficulties, such as problems sleeping, poor impulse control, self-injurious behaviour, refusing to go with certain people or do certain things, sexualised and high-risk behaviour. There are also more personalised behaviours that may be observed such as not being able to self sooth or reward themselves, specific coping strategies like disassociation, shielding from shame, or even re-enactment of difficult relationships, and controlling or mistrust of others.
When barriers have meant secure attachments have not been formed, behaviours of concern later in life are more likely to be presented and experienced. Unfortunately, this can lead to further trauma being experienced by individuals throughout their life because of a higher risk of intentional and unintentional abuse from the individuals who support them when reacting or responding to behaviours of concern.
There is a real risk here that, because of the intensity and frequency of some of the behaviours of concern presented, we can focus more on the behaviour in front of us rather than its function, forgetting the importance of connection, and fall into the trap of correcting rather than understanding.
Examples of these could include:
- Excessive restraints used for long periods of time.
- Disproportionate responses around consequences or punishments.
- Physical, sexual, or emotional abuse.
- Lack of support after a loss or bereavement.
- Multiple placement moves.
- Expecting individuals living with a learning disability to manage in an environment that is not set up for their needs.
- Medication, such as those given ‘when required’ (PRN) which may include sedatives which can make the individual feel unwell or lethargic.
- Abuse or neglect from an organisation.
- Individuals left in rooms for long periods with no or little interaction with staff or peers.
It’s important for individuals who have experienced attachment difficulties and trauma to get the right support that makes them feel safe, and this does not necessarily need to come from specific trauma support services.
Looking for ways to provide the best support
There are changes we can make across the home environment, our ethos and values, routines, and our own responses that can help individuals have positive relationships. These can include using small consistent staff groups, developing relationships that are built on emotionally available adults, and having consistency by behaving the same way towards a person. Body language and tone of voice helps establish trust and respect. We can also honour the ending of relationships to enable the person to grieve, for example, if staff need to move on.
Introducing activities based on self-regulation and stabilisation can be a useful strategy in supporting individuals to feel calmer and help avoid triggering the threat system. Offering these activities little and often can help build therapeutic relationships using patterned, rhythmic activities that ensure individuals know they are safe. Activities can include music, walking or dance, tapping or drumming and should be offered by a safe person, be enjoyable, patterned and relevant.
Considering physical health conditions
If we know older adults in our care have experienced attachment difficulties or trauma, we need to consider the possible impact on physical health. Lifelong physical health conditions, such as cancer, vascular dementia, diabetes, and irritable bowel syndrome, are just some of the risks linked with prolonged exposure to trauma and attachment difficulties.
For individuals with learning difficulties, some of the barriers mentioned earlier, such as speech, language and communication needs, mean communicating symptoms can be difficult and confusing. It is important that symptoms are recognised early to enable access to treatment as soon as possible. This can include:
- Keeping clear records of sleep patterns, toileting routines, and appetite.
- Making sure appointments are attended.
- Keeping mood charts or recording changes to behaviour and personality changes.
Sharing these records between staff teams is important to understand individual needs not just during a shift, but over time.
If we don’t consider the experiences some of our older individuals have had, and the potential impact of attachment and trauma, there is a serious risk that the strategies we use will be inappropriate to individual needs and ultimately unsuccessful.
For support to have a better chance of success, it should be based on relational security, emotional support, understanding the function of behaviour, and have a focus on trauma informed models of care. Support plans should be delivered with the individual at the centre of their care, considering how past experiences and associated feelings could be driving behaviours of concern.