title: Some communication procedures and recommendations for reducing aggressive behavior in an individual with moderate intellectual disability in a social service home type: Article language: English published: 24 Sep 2013 updated: 24 Sep 2013 category: Sociálna práca author: Mgr. Karola Martáková Introduction

Communication with an individual with moderate intellectual disability (MID) is specific, both in content and form, due to his impairment. Providing communication support for this individual is needed, since understanding his verbal needs and wishes is limited by his restricted communication abilities. Expressions of aggression are often the only way this individual can express himself, make himself visible, and request the attention he did not receive in early childhood, and therefore he feels that even in adulthood he does not receive enough. In some cases an individual with MID cannot explain the causes of his aggressive behavior, cannot describe the condition, emotions, and needs he has at the moment of brachial behavior toward the surroundings. For this reason, it is necessary that he is guided. The role of social workers, special educators, psychologists in social service homes and doctors, as well as family members, is to identify the causes of aggressive behavior, analyze them, and through suitable interventions reduce inappropriate behavior so that the individual’s behavior is directed in a positive direction.

Definition of terms

Currently, Valenta (2012, p. 31) defines intellectual disability as “a congenital developmental disorder of intellectual abilities, mainly affecting cognitive, speech, motor, and social abilities”. Vágnerová (1999) and Požár (2007) consider the criteria of this disorder to be a low level of intellectual abilities, that the impairment is congenital and permanent. However, it should be noted that depending on environmental influence, suitable therapeutic and pharmacological intervention can lead to improved functioning and appropriate sociality of a person with MID. We can identify four groups of intellectual disability, which we divide by severity (Čadilová et al., 2007) into: mild intellectual disability (IQ 50–70), moderate intellectual disability (IQ 35–49), severe intellectual disability (IQ 20–34), and profound intellectual disability (IQ below 20). In this contribution, we focus on the group with moderate intellectual disability (F71). Individuals with this diagnosis make up the majority of clients in social service homes. A person with MID can, despite limited verbal communication, still express a request and can provide or request information (Čadilová et al., 2007).

Aggressive behavior can be defined according to Vágnerová (1999, p. 266) as “a violation of social norms. It is a means to achieve satisfaction that is obstructed by barriers.” This kind of behavior can be, according to Powers (2005), directed against other people, against oneself, or against property, and in individuals with MID manifests as squeezing, poking, pulling hair, or biting. Most individuals with this diagnosis do not present an increased risk of violence (Puddicombe, Lunsky, 2007).

Communication is every mutual exchange of information. It is the mutual interaction of people who communicate and consists of the sending and receiving of verbal and nonverbal expressions (Rybár et al., 2005).
In the following text, we describe the causes of this behavior and a case study including the social history of an individual with MID with aggressive behavior.

Case study The young adult Martin, aged 21, came to a social service home on the basis of a court decision because, for the person appointed by the court as guardian (his biological father), his basic life needs were not being met and Martin, due to his moderate intellectual disability, was unable to care for himself. Martin was born to a mother who herself has mild intellectual disability, and Martin has been diagnosed with fetal alcohol syndrome. The mother could not care for the child, and the child suffered deep emotional deprivation from early childhood. The parents separated during Martin’s preschool years, and Martin, a minor, was assigned to the father. Martin has a 14-year-older brother without disability, whom his maternal grandmother raised. At the age of 12, Martin, with moderate intellectual disability, was found by police at the central railway station of the big city, where he had come completely alone on a bicycle from home from a peripheral district of the city (about 15 km away). The police located his father, called him for questioning, and the father gave testimony under the influence of alcohol and, when leaving, left Martin at the police station and did not bring him home. After this event, Martin was placed in a children’s home 150 km from the city. Parents and brother of Martin visited only sporadically. At age 18, the adult court again entrusted Martin to his father and appointed him as Martin’s guardian. The children’s home paid Martin an initial grant of €8,000 for independent living, which marks the end of Martin’s stay there. The father worked as a guard on 24-hour shifts; Martin was left alone at home, and from the apartment one could hear crying, screaming, frantic banging on the door. Martin was left alone without supervision, without food, for long hours and days in isolation and with fear of hopelessness. Following complaints from neighbors, the local authority of the city district intervened, and by court decision Martin was admitted on 28 August 2011 to a social service home (hereinafter DSS). Martin has been in the DSS for two years. His parents visited the son individually once a week. After Martin’s parents came together to the DSS on 30 April 2012 and Martin saw them together, their presence most likely triggered home conflicts, physical attacks, and anxiety in Martin. From then on Martin began in unexpected situations to attack DSS staff from behind physically, including pulling the hair of female staff, which continued for 5.5 months. In the DSS there was fear and a sustained threat from Martin’s client behavior. Several staff members gave notice of termination because of ongoing threats from Martin. Meanwhile, social workers, special educators, and psychologists at the DSS urgently sought the causes of Martin’s behavior, identified the situations in which his brachial behavior occurred, tried proposed methods, and organized two supervisions on the topic of “Martin.” Over this period, Martin was, on average, taken by ambulance to hospital eight times per month, and he was hospitalized three times on the psychiatric ward of the city hospital for a total of 4 weeks. Martin’s brachial behavior repeatedly returned immediately on the day of his return from hospital. On 12 October 2012, Martin was successfully hospitalized in a regional psychiatric hospital 20 km from the city, where, after a week when they wanted to return him as a non-problematic patient, the staff experienced a massive attack by Martin against hospital personnel. After a month, Martin returned from the regional psychiatric hospital with adjusted psychiatric medication. During Martin’s hospitalization, professional staff at the DSS gathered at work meetings, where they intensively sought a suitable professional and human approach to Martin so that he could be given new living conditions in the DSS and enabled to socialize without aggressive behavior toward the environment. Martin returned, and the professional staff began to apply rigorously the agreed individual therapy procedure, which we successfully present in the following text after 10 months. Causes of the emergence of aggressive behavior in an individual with moderate intellectual disability

We can identify several causes for the emergence of aggressive behavior in individuals with MID. Reasons may include: organic or functional brain damage, unfavorable environmental influence, inappropriate approach from the surrounding environment, strict rules imposed in the organization, or an individual with MID’s inability to communicate their needs.

Aggressive behavior in individuals with MID is caused by organic or functional brain damage, when situations arise in which these individuals cannot adequately control their own emotions (Čadilová et al., 2007). It should be noted that the most common cause of crisis is aggression. An individual with MID cannot explain this type of behavior and does not know what is causing anxiety, which can be expressed as self-harm or maladaptive behavior (Hauser, Silka, 1997). Buddicombe, Lunsky (2007), in their study, also examine the possibility that maladaptive behavior may be caused by comorbid mental illness, as a consequence of which an individual with MID becomes more aggressive and harder to manage.

Negative influence on aggressive behavior can also come from an unsuitable environment in which an individual with MID is located (Čadilová et al., 2007). Some studies report that irritability is caused by noise (Nursing Management of Agression, 2011). Similarly, the high number of clients in a facility where an individual with MID lives can cause greater aggression. Based on these statements, it is possible to manage aggressive behavior of an individual with MID effectively, provided that adverse stimuli are appropriately minimized or removed.

A cause of aggressive behavior is also the content and form of approach from other people. Individuals with MID in many cases do not have the possibility to decide for themselves (Platt et al., 2013). In the practice with Martin, it proved useful to let him experience a negative experience, which helped prevent his aggressive behavior. It should, however, be noted that it is necessary to assess the risks of such a negative situation. We provide a specific example. We did not stop Martin during a trivial activity such as putting on a jacket even though the weather was sunny. We let him decide and act as he himself considered appropriate. As Čadilová et al. (2007) state, this way the individual with MID strengthens his own competencies and independence. It should be noted that Martin later realized on his own that he had decided incorrectly and during the walk he removed the jacket. In this way we avoided his aggressive behavior in that situation and he gained a personal experience that gives him the opportunity to react differently in the future.

Aggressive behavior can also be caused by the pressure and requirement to conform to a system represented by strict rules in the facility. Pörtner (2009) notes that therefore it is necessary to realize that most people in the general population would behave in the same way in the same situation. In addition, individuals with MID react more sensitively to changes and, as can be seen in practice, various stressful situations can speed the emergence of inappropriate behavior.

The reason for aggressive expression by an individual with MID can also be the inability to express what he wants to say (Prouty, in Pörtner, 2009). In practice, we often encounter situations where an individual with MID uses violence as a response, which, as Reuve and Welton (2008) emphasize, prevents him from developing more appropriate ways of responding to various situations. As we mentioned in the introduction, through environmental influence and appropriate therapeutic and pharmacological intervention, it is possible to teach people with MID to express themselves more appropriately, which we will outline in the following text.

Among other factors that significantly affect the occurrence of aggressive behavior in individuals with MID are unmet basic life needs, discomfort, deterioration in health status, lack of attention, abuse, neglect, family chaos, and disruption of social relationships (Jůn, 2007, Hauser, Silka, 1997, Powers, 2005). According to Jůn (in Čadilová et al., 2007), it is not possible to avoid problem behavior of an individual with MID in every situation.

Communication options with an individual with aggression and moderate intellectual disability

In individuals with MID, due to irregularity in psychomotor development, communication is also disturbed. There are appropriate ways to develop communication skills in these individuals (Vančová, 2005). Hauser and Silka’s (1997) statements also prove this by emphasizing which communication skills to use when communicating with an individual with MID. According to their findings, one should speak to individuals with MID in as specific a way as possible, corresponding to their level of understanding. Vágnerová (1999) shares this claim; according to her, people with intellectual disability have difficulties understanding ordinary verbal expression due to limited vocabulary and similarly difficulty understanding the overall context. In communication with Martin and other individuals with MID, we found it useful to slow down our speech, use short sentences and questions, and also attend to nonverbal expression as a response and a sign of understanding. Similarly, it is necessary to observe such an individual, to notice his expressions and methods, since he often cannot adequately express himself with words. By accepting his own pace and behavior expressions we can understand his actions and comprehend them. We proceeded from the pretherapy method developed by the American psychologist Garry Prouty (in Valenta et al., 2012). This method enables the establishment of contact based on the client’s concrete perception. Prouty et al. (2005), in their pretherapy approach, highlight observation of a person with intellectual disability; through his own expressions and repetition, it is possible to enable this person to establish contact with himself and with his life. According to Valenta et al. (2012), the result of using this method can be improved contact with reality and greater involvement in communication with the environment. It is clear that through understanding by others and increased self-confidence, the quality of life of an individual with MID can be improved.

In crisis situations, communication with an individual with MID requires, according to Čadilová et al. (2007), establishing a calm atmosphere. Pörtner (2009) assumes that it is necessary not only to take seriously the views of a person with MID, but also not to impose one’s own beliefs on the developing situation and to respect him. In addition to these claims, practical experience has shown in our work that during communication it is useful not to raise one’s voice toward a person with MID, to maintain control over the situation, and to believe that we can handle the situation together.

If the methods listed above do not prevent effective handling of a crisis situation, it is necessary, as Čadilová et al. (2007) state, to use restrictive measures. It should be noted that these are physical or mechanical restraints. Physical restraint of an individual with MID takes precedence over mechanical interventions (a muzzle-like restraint) and the use of medication. As we experienced in practice in Martin’s case, behavior in which such a person threatens staff or family may require his hospitalization. The person with MID should be examined thoroughly (Unpublished author, 2007). It is also necessary to exclude or confirm the presence of psychiatric disorders that could be the cause of aggressive behavior. This view is also shared by Powers (2005), who supports identifying the cause of the aggressive behavior and setting treatment that reduces the degree of risk behavior. However, it should be noted that medication calms a person with MID, but it is the responsibility of the staff to whom the person is entrusted to assess the cause of behavior effectively, evaluate key problems, likelihood of recurrence, recognize warning signs of a crisis situation, and propose measures to reduce the frequency of aggressive behavior (Hauser, Silka, 1997, Powers, 2005).

According to Pörtner (2009), aggressive manifestations of an individual with MID should be discussed with the person, his family, and other professionals. Powers (2005), based on his study, proposes examining the client’s life circumstances, and also the impact of stress-provoking situations (in Martin’s case, change of housemate, death in the family), which occurred and could trigger aggressive behavior.

Sobek (2008) recommends recording various problematic situations to which an individual with MID is exposed. Mapping these circumstances (when, where, with whom, and under what conditions they occurred), what preceded them, how they unfolded, and what followed significantly affects the possibilities of preventing similar situations in the future and, based on acquired experience, responding more appropriately.

A person with MID can learn appropriate behavior, according to Čadilová et al. (2007). If he is able to respond in another more appropriate way, he should be rewarded with what is truly rewarding for him. Rewards can reduce the amount of problematic behavior and number of aggressive manifestations, while simultaneously increasing the likelihood of desired behavior (Nursing Management of Agression, 2011).

Another preventive intervention against aggressive behavior is teaching an individual with MID an appropriate way of expression. Pörtner (2009) supports giving freedom for expression to the individual with MID, through which they can express emerging emotions, accept them, and not suppress them. In the professional literature, it is stated that the role of social workers, special educators, and psychologists in social service homes is to teach a person with MID that emotions cannot be labeled as either right or wrong (Nursing Management of Agression, 2011). Conversely, we can teach an individual with MID communication through gradual regulation of emotions: help a specific individual identify the emotion, let him describe the situation, practice different situations with him, express that emotion in real-life situations, look for different ways of expressing the emotion, and confront the person who is the source of that emotion. During learning these methods it is essential to provide support to the person with MID while gaining and maintaining these skills (Powers, 2005). In practice, we found that with a clearer description of the situation to such a person, understanding develops. Then he can handle the situation better, which contributes to overcoming aggressive behavior. There is clarification of the situation and release of tension on the part of the person with MID.

So that a person with MID can communicate and respond to situations in a more appropriate way in which aggressive behavior could occur, it is useful to develop a crisis intervention plan for a high-risk situation together with them. The individual items were created based on specific questions listed by Sobek (2008) as suitable in creating such a plan. They include risk identification, describing the hazard, incidents in similar situations in the past, whether the client is aware of the risk, the significance of the risk situation for the client, and how the risk will be minimized.

In the following text, we present Martin’s concrete example of a risk-management plan (an individual with aggression and MID), which we created following the steps listed by Sobek (2008) in his publication.

Crisis management plan A. Risk identification 1. Martin is restless and frightened. He repeatedly paces and repeatedly performs the same activity (e.g., goes to the toilet). 2. Martin is restless, shifts from one foot to the other and asks whether he has done something wrong. 3. Martin starts shouting, throws shoes, attacks staff and other clients. B. What danger does the client face? 1. Martin may become even more agitated. It is necessary to stay with him and calm him down (e.g., walk to the toilet with him several times so he can gain confidence that he will not be left alone). 2. It is appropriate to talk to Martin in a calm voice, and possibly hold his hand. Reassure him that he did nothing wrong. His questions must be answered patiently. 3. In this case Martin may harm himself, staff, or other clients. If the situation is dangerous, it is appropriate to call for emergency medical help. C. Has an incident occurred in similar situations in the past? 1. Yes. This situation has repeated itself many times. It is necessary to explain to Martin that he has already done this activity. Then redirect his attention to the activity he had been doing. 2. Yes. Martin often does not know if he has done something wrong. He needs to be continuously reassured that everything is fine. 3. Yes. Martin has already broken various objects, torn clients’ and staff’s pajamas and T-shirts, bitten off the limbs of plush toys, attacked other clients, and pulled hairs from their arms. D. Is the client aware of the risk and potential consequences? 1. Martin feels something is not right, but cannot verbalize it. 2. Martin is aware that something is happening. 3. Martin does not realize that he may injure someone or himself. E. What is the significance of the situation for the client? 1. Martin feels insecure. He wants to draw attention to himself. He needs someone to be with him and with him. 2. Martin often does not know how he feels himself and what he should do. 3. In this situation Martin loses control of the situation and his behavior becomes unpredictable. F. How will the risk be minimized? 1. Give Martin greater attention and, at the beginning or in an imminent risk situation, provide exclusively individualized attention. It is essential to speak to him calmly, in an environment without distracting stimuli, to listen to him, and to find a joint solution to the situation. 2. Martin needs to be assured that he is doing the activity he is performing well. 3. By calling emergency medical help, a specialist doctor, or by adjusting medication.

Conclusion

In this article, we tried to outline how to communicate with an individual with aggressive behavior and moderate intellectual disability, what procedures can reduce aggressive behavioral expressions, and we deal with causes of the emergence of aggressive behavior. We emphasize that in communication with an individual with aggression and moderate intellectual disability, one must understand him, let him experience different situations so he can internalize the experiences, help him learn to express his needs, and thereby prevent aggressive behavior. In our view, it is essential to gather as much information as possible about a given individual from their documentation, from people who know him, through observation, and through team discussion, so that we can understand his expressions as well as possible, avoid them or transform or redirect them. In our contribution, we stress the need to speak about problematic situations in an appropriate form with an individual with moderate intellectual disability, through which such a person can better understand the situation being experienced and learn to respond more appropriately. In practice, the development of crisis plans helped us with Martin and other DSS clients; these plans describe the problematic situation and ways of resolving it in the past. We are aware that we did not manage to cover the full range of different types and levels of communication with individuals with aggression and moderate intellectual disability. We believe, however, that our communication experience with Martin may help other colleagues on their long path of search, at least as much as it helped us.

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