1. Bolton Learning Disability Audiology Services and Challenging Behaviour

2. LD Audiology Adult Services in Bolton  Audiology dept. is based in the Acute Trust, but sees clients in a wide variety of settings  Introduced LD hearing screening over 12 years ago- initially not universal screening  Also provides diagnostic audiology and rehabilitation

3. Strengths of Bolton Team  Only staff interested in working with LD adults on the team  Working in partnership with other professionals  Treat everyone as an individual, trying to understand their needs and what motives them  Provision of high quality aids that best meet clients needs  Dedicated transition team

4. What is Challenging Behaviour? Emerson et al (1987) suggested that; “Severely challenging behaviour refers to behaviour of such an intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to seriously limit or delay access to and use of ordinary community facilities.”

5. Challenging Behaviour Foundation Some children and adults with severe learning disabilities typically display behaviour which may put themselves or others at risk, or which may prevent the use of ordinary community facilities or a normal home life. This behaviour may be in the form of aggression, self injury, stereotyped behaviour or disruptive and destructive behaviours. These behaviours are not under the control of the individual concerned and are largely due to the individual’s lack of ability to communicate.

6. Why audiological assessment and screening is so important for LD adults with challenging behaviour?  Possible self harm or foreign bodies  Progressive hearing loss may go undiagnosed if alongside other progressive condition e.g. dementia  Effects of hearing loss compounded by poor communication tactics and other disabilities  Often no continuity of carer  Difficult to spot early signs of infection/discomfort  Examination/testing can be difficult  Ear pain/hearing loss may compound challenging behaviour  LD increases probability of having hearing difficulties and higher incidence of premature aging

7. Incidence of Hearing Loss in Adults with LD Research Evidence on the Health of People with Learning [Intellectual] Disabilities First published by the Valuing People Support Team in 2002Valuing People Support Team “Around 40% are reported to have a hearing impairment”

8. Incidence of Hearing Loss in Adults with Downs Syndrome

9. Effects of Hearing Impairment on Adaptive Behaviour in Adults with Downs Syndrome Prasher V.P. 1995 studied Adults with DS and looked at the effects of hearing loss “Hearing impairment leads to a loss of adaptive skills and to an increase in maladaptive behaviour for individuals below the age of 40 years.” “Deterioration in adaptive functioning cannot be assumed to be due to dementia in people with DS unless the presence of hearing impairment has been excluded.” Mean age for each group between 40 and 48 years 201 Adults with DS, living a range of environments took part in the study

10. Meet the team that allows us to work with this client group Audiologists LD assistant practitioners Social Care Staff Trust Specialist LD Nurse Audio-vestibular Medicine ENT SALT Advanced Practitioners in Audiology Advanced ENT Nurse Practitioner

12. Screening and review sessions This involves: Co-ordinating availability of staff, clients, transport and facilities Monitoring review and referral lists- chasing DNA’s Understanding and allowing for clients preferences and dislikes Obtaining consent and generating appointment schedule Conditioning of clients with challenging behaviour and briefing carers Being a familiar face supporting Audiologists during investigations Recording and communicating results and recommendations in appropriate format These sessions are arranged with audiology, care homes, day centres etc by the LD assistant practitioners.

13. Audiology Screening and assessment appointments o Briefed on clients preferences and dislikes- documented for future appointments o Venue is safe and a place where client is relaxed o Staff don’t wear uniforms o Staff present are those the client is likely to respond well to and are able to provide insight into clients behaviour o More than just a hearing assessment- ears checked and aural care issues addressed

14. Audiology Screening and assessment appointments o Adequate time given, several visits if necessary o Flexible approach to testing- being creative and making use of behavioural changes o Be prepared for the unexpected-assume nothing o Treat clients with respect e.g. “Toys” are not childish o Clinical governance guidance followed

15. Appointments Alerts on clients in audiology booking system Those requiring 2 of LD staff or other special requirements noted Variable lengths of appointment with most appropriate member of staff, dependent on patients needs Encourage regular carers to attend with clients Fast track appointments when possible to minimise time in waiting room Use large test room and friendly facilities

16. Working with other professionals in the hospital Close relationship with Trust LD nurse Co-ordinate hospital appointments to minimise disruption If GA or sedation being use opportunity to check ears, take impressions, perform objective tests etc. Share experiences and personal development opportunities Collate any concerns regarding an individuals care

17. Rehabilitation o Take time to build a relationship with client and carers o Mild losses may not require aiding as good communication tactics are employed by carers in a consistently good listening environment o A realistic rehabilitation plan needs to be developed and agreed in partnership with stakeholders o Ensure the care plan is communicated to all staff working with the client and a consistent approach is maintained

18. Hearing Devices o Agree benefits and care plan, build in checking aid is functioning and ear is not sore o May be unable to communicate if aid uncomfortable or too loud, set conservative output limits. Remember client may be in very noisy environments o Use quality products that best meet clients needs- consider using high end products with additional features e.g. water resistant o Malformation of pinnae and narrow ear canals can present additional challenges o Motivation- Find ways to reward cooperation o Consider and minimise risks

19. Transition Team 3 of the audiology staff are members of both the LD adult and the team that works with clients moving from paediatric to adult hearing services. One of the Audio-vestibular Medicine Doctors has a keen interest in this client group and works across both services.

20. Pressures we still face LD Children that have not accessed local audiology services could be missed How to consult effectively with these clients and their carers when developing services Ensuring equality and access with new financial pressures and management structures Monitor quality of services across UK, when no detailed standards available and introduction of individual care budgets Access to high quality training and development for all professionals

21. Example of local Audit

22. Use information to drive service improvement Research and audit data Record referrals and activity Data that allows us demonstrate collated outcomes Need to document and share evidence of practices e.g. risk assessments

23. Final point to take away No BIG answer and Bolton still has a long way to go. However, working together, focusing on and trying to meet each clients needs, is a must when providing services for LD adults with challenging behaviour.

24. Thank you and remember; The most valuable lessons are often learnt when facing adversity.