Mar 4, 2004 - comparison services (non-active support houses). Results All ... Engagement of service users in daily activities is an important measure of ...
Journal of Applied Research in Intellectual Disabilities 2004, 17, 139–148
Implementation and Evaluation of Active Support Jill Bradshaw, Peter McGill, Rachel Stretton, Amanda Kelly-Pike, Jane Moore, Susan Macdonald, Zoe Eastop and Bob Marks Tizard Centre, Beverley Farm, University of Kent, Canterbury, Kent CT2 7LZ, UK
Accepted for publication
4 March 2004
Objectives Active support was implemented in three community houses (active support houses), with 11 service users with severe learning disabilities. Methods This was evaluated with reference to changes in levels of engagement, challenging behaviour (major and minor) and staff contact, measured against three comparison services (non-active support houses). Results All measures increased for the active support houses. Significant increases in activity levels were found in one house. Statistically significant increases in activity and minor challenging behaviour were also
Introduction Engagement of service users in daily activities is an important measure of service quality (Emerson & Hatton 1994; Felce & Emerson 2000). In their review, Emerson & Hatton (1994) found that levels of engagement in staffed houses averaged 47.7% (range 8–74%). Engagement levels are influenced by a number of factors. For example, high levels of engagement are typically associated with high levels of assistance (Felce et al. 1986) and more able service users (Felce 1994). Staff typically give more assistance to those who are more able despite those with greater disabilities needing more help to engage in activities (Duker et al. 1989). Despite these research findings on the importance of staff support, staff contact is typically around 15% (range 5–31%) in staffed houses (Emerson & Hatton 1994) with only a small proportion of this contact consisting of support to take part in activities (Hewson & Walker 1992; Felce & Perry 1995). Levels of challenging behaviour may interact with engagement in activity. Jones et al. (2001b) commented that opportunities to take part in activities may lead to increased demand-related challenging behaviour. They 2004 BILD Publications
found when all active support houses were compared with all non-active support houses. In the non-active support houses, all measures decreased, with the exception of mean level of staff contact in one house. Conclusions Unlike previous research findings, those service users who were less able did not receive comparatively more support from staff post-training and changes appeared unrelated to staff contact. Keywords: active support, engagement in activity, severe intellectual disability, staff training
further hypothesized that self-stimulatory behaviour may decrease given increased opportunities to engage in constructive activities. Recent research (e.g. Jones et al. 1999, 2001a,b; Felce et al. 2000) has demonstrated that a combination of classroom-based and in-house training in active support can be effective in increasing service user engagement. The present study was an attempt to replicate and extend findings regarding the implementation of active support. Active support is a package of procedures designed to increase the effectiveness of staff support given to service users by tailoring support to meet needs (McGill & Toogood 1994; Mansell 1998; Jones et al. 1999, 2001a,b; Felce et al. 2000). Jones et al. (1999) carried out an evaluation of active support training with a total of five houses, involving 19 service users using a multiple baseline design. They found increases in service user engagement in activity and in the level of assistance provided by staff. Increases in engagement were positively and significantly correlated with increased assistance after training, with average percentage levels changing from 33.1 to 53.4% for engagement, from 17.5 to 31.8% for contact and from 5.9 to 23.3% for staff assistance. Similar findings (although with smaller increases) were found in an extension of the
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original study (Jones et al. 2001a). Challenging behaviour was unaffected by the intervention. Service users who are less able have been found to benefit more from active support (Jones et al. 1999). Jones et al. (2001a) demonstrated that the value of the approach diminished when used with people with Adaptive Behavior Scale (ABS) (Nihira et al. 1993) scores between 151 and 210 and report that the approach is not suitable for those with ABS scores of greater than 210. Jones et al. (1999) commented that staff turnover and lack of training for new staff contributed to the deterioration of active support over time. One way to address these issues would be to involve service managers in implementation. Jones et al. (2001b) compared three methods of implementation and found that active support was fully implemented when the researchers led the training with manager assistance or when these managers led the training with researcher assistance. When training was led by these managers alone, the interactive (on-the-job) training was not fully carried out. Significant increases in engagement and assistance were only found with models one and two. Jones et al. (2001b) suggested that interactive training may therefore be the key factor in producing significant results.
Method Settings Staffed homes in community settings were established to replace the small long-stay hospital where service users had previously lived. Each of the staffed homes was managed by a not-for-profit organization. This organization had taken over the running of the services in January 1998 prior to moving to the community. Houses opened in late 1999 and early 2000, after a lengthy delay. All training was carried out in these houses and in a local classroom setting.
Participants Thirty-eight staff (68% female and 32% male) were included in the training, from three community houses, 31% of whom had previously worked in the long-stay hospital. Staff characteristics can be seen in Table 1. Twenty-two service users (20 men and 2 women) lived in six houses. All service users had severe or profound learning disabilities and had been institutionalized for long periods of time (mean 29 years and range
Table 1 Staff Characteristics House A
B
C
Average
Comparison Houses***
Number of staff Male ⁄ female Mean age (years) Mean time in working in learning disability services (years) Mean years working for current service provider Mean years working in this community house Number of staff who had previously worked at the hospital
10 3⁄7 38.6 4 1.4 0.5 3
12 5⁄7 35.5 5 0.8 0.3 1
16 4 ⁄ 12 38 10 1.9 0.7 8
13 – 37.4 6.3 1.4 – –
29 (57%) 10 ⁄ 19 38 7.5 – 4 –
Highest educational level Degree Diploma ⁄ city and guilds ⁄ BTEC ⁄ RSA ⁄ NVQ ⁄ nursing qualification* A level or equivalent GCSE or equivalent No formal qualifications
2 6 – 0 2
3 4 – 3 2
1 9 – 2 4
2 (16%) 6.3 (50%) – 1.7 (13%) 2.7 (21%)
5% 40% 5% 50% –
0 6
0 4
5 0
1.7 (13%) 3.3 (26%)
Nursing qualifications related to learning disability Staff with nursing qualifications related to learning disability* Staff with other qualifications related to learning disability**
6 (21%) 3 (10%)
* For the hospital sample, all nursing qualifications are in the last section of the table, regardless of whether they are learning disability related. ** For the hospital sample, this is other qualifications relating to the care profession. *** Comparison sample data taken from representative sample (57%) of staff whilst working in hospital setting in 1997.
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Journal of Applied Research in Intellectual Disabilities 141
9–55 years). Staff of three of these houses received active support training (houses A–C), whilst the remaining three served as comparisons and received no intervention (houses X–Z). Characteristics of each service user, divided into the six houses, can be seen in Table 2, in comparison with service users by Jones et al. (1999) also provided in Table 3. Data are unavailable for two service users (23 and 24) as they did not move into the houses until a later date. In addition to differences in design from the study by Jones et al. (1999), with the present study using comparison houses rather than a multiple baseline design, houses were less established having been opened for an average of 0.6 years (range 0.3–0.7 years) prior to the training as opposed to an average of 4.8 years in the study by Jones et al. (1999). Although baseline levels of engagement were comparable for the non-active support houses (29.1% compared to an average of 33.1% according to Jones et al. (1999)), levels for the active support houses were half that of the Jones study at 16.6% (14.6–17.7). Service users were generally less able and had more additional disabilities – in particular, challenging behaviour was displayed by 85% of service users compared with 21% by Jones et al. (1999).
Procedures Consent Support was sought from the relatives (where known) of all participants prior to commencement of the research programme by means of a letter explaining the overall aims of the project. Additionally, consent was sought from all clients. Where it was not possible to gain informed consent, staff were consulted regarding the individual, and it was agreed that should the person display any behaviours that could be interpreted as ‘non-consent’, the collection of data would cease. One service user was able to give consent and no service users were observed to behave in ways suggesting nonconsent.
Active support training Staff at all levels in the organization were involved in the planning stages to encourage successful implementation. Active support training consisted of classroombased training with each individual staff team followed by sessions with the trainers in each house (interactive training). Trainers also attended a number of house staff meetings.
The workshops for houses A and B consisted of two consecutive days of training for the entire staff team. The materials for the workshops were based on a training package developed by the Welsh Centre for Learning Disabilities (Jones et al. 1996, 1997) and on earlier work on ‘whole environment training’ (Mansell et al. 1987,1994; Hughes & Mansell 1990; McGill et al. 1991). Outlines of the sessions and aims can be seen in Table 4. Houses A and B received the training in November and December 1999. House C training was postponed until April 2000 because of staff shortage. During training for houses A and B, it became apparent that there was limited ownership of the training by the houses and confusion regarding the aims of active support at a managerial level. The lack of house manager involvement in interactive training (despite initial staff rotas having scheduled sessions for when house managers were on shift) was problematic in terms of ongoing implementation of active support and continued support to staff. It was clear that more support was needed in the implementation and management of the systems and structures around active support. Training for house C was therefore organized to address these issues, with the entire staff team receiving 1 day of the classroom training in April 2000 (see Table 4 for sessions covered) to cover the basic elements of active support. There then followed four sessions in May and June 2000, where the trainers worked with the house mangers and the house deputy managers (or other people in the house who were interested and planned to take a lead on active support within that service) from houses A–C. The service manager was present throughout all sessions and the operational manager attended the first and last sessions. These four sessions included both topic-focused meetings and tasks for the staff to carry out in their houses. Interactive training sessions involved trainers working with staff in the houses to implement the active support approach and to assist staff to tailor their support strategies to individual needs. These sessions took place immediately following the classroom-based training in houses A and B. The interactive sessions for house C took place with one external and one internal trainer and over a longer time period. Trainers spent 2 h with each member of staff in the active support houses. Following an initial discussion, the trainers observed that member of staff whilst they were working with a service user of their choice. This observation session typically lasted about 10 min. The trainers and staff member then discussed the activity and worked together to identify the strengths of the
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14
23*** 10 11 12
20
17 22 18 19
08 15 21 13 16
07 01 03 04
24*** 05 06
Service user
None None Mobility difficulties because of ageing Cerebral palsy ⁄ spasticity ⁄ angina
None None None Paraplegia Cerebral palsy ⁄ chored-athetotic movement None Senile dementia None Minor tongue abnormality None
None Cerebral palsy ⁄ spastic quadriplegia ⁄ kyphoscoliosis Spastic triplegia Spastic quadriplegia Spastic quadriplegia Spasticity of right leg
Physical diagnoses ⁄ additional difficulties
No
No Yes No
Yes
No No No No
No Yes No Yes No
Yes Yes Yes No
No Yes
Epilepsy
Normal
Normal Normal Slight loss
Staff report normal
Inconclusive Normal Mild loss Normal
Normal Normal Normal Slight loss Hearing aid
Normal Normal Inconclusive Staff report normal
Inconclusive Unable to assess
Hearing
54
83 69 97
103
108 173 178 75
119 66 126 111 140
39 29 53 51
100 43
Total ABS score
needs help with fastening; and
**
Beginning of cataracts
Normal Slight deficit Normal
Staff report normal
Normal Bifocals Normal Normal
Strabismus Normal Mild loss Cataracts partially sighted Normal Normal Normal Glasses Normal
Mild loss Normal
Vision
As in 1997, unless stated otherwise: *independently or with verbal prompts; data collection.
Z
C
Y
B
X
A
House
Table 2 Service user characteristics
No
Yes No No
Yes
No No Yes No
Yes No Yes No Yes
No No No No
No No
Continent
Yes
Yes Yes Yes
Yes
Yes Yes Yes Yes
Yes Yes Yes Yes Yes
Yes No Yes Yes
Yes No
Feed*
No
No No No
Yes
Yes Yes Yes Yes**
Yes Yes** Yes** Yes Yes
No No No No
No No
Dress*
No
No No No
No
Yes Yes Yes Yes
No No Yes** Yes** Yes
No No No No
No No
Wash*
No
No Yes Yes
No
No Yes Yes No
No No Yes Yes No
No No No No
No No
Speak in sentences
moved in at a later date and so not part of original
***
No
Yes Yes Yes
Yes
Yes Yes Yes Yes
Yes Yes Yes No Yes
No No No No
No No
Walk*
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includes one service user who moved in at a later date and so not part of original
As in 1997, unless stated otherwise: *independently or with verbal prompts; and data collection.
85 21 59 26 Current study (%) Jones et al. (1999) study (%)
45 42
3 1 3 4 3 3 17 2 2 0 3 3 3 13 4 3 3 4 4 4 22 A** X B Y C** Z Total
3 3 0 2 0 2 10
Challenging behaviour Sensory impairment Physical disabilities Residents House
Table 3 Service user characteristics per house
**
5 16
54 74
27 74
81 90
45 47
26 47
27 42
ABS score mean total 91 115
61 44 104 133 119 76 0 0 1 2 1 2 6 0 0 0 1 0 0 0
0 0 3 3 3 3 12
0 0 2 1 2 1 6
2 2 3 4 3 4 18
0 0 3 4 3 0 10
0 0 1 4 2 0 7
ABS score mean (range) Mental illness
Walk*
Continent
Feed*
Dress*
Wash*
Speak in sentences
(39–100) (29–53) (66–126) (108–173) (75–178) (54–97)
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member of staff and to agree priorities for the interactive phase of the training. These can be seen in Table 5. The trainers and member of staff then worked together, supporting service users to participate in activities. After a repeat observation, the trainers and member of staff discussed the session, and together set some targets for increasing participation and reviewed the process (see post-interactive training feedback in Table 5).
Data collection Observations of service user and staff behaviour Momentary time sampling using 20-s intervals was used during observations at two time points. The first observation (T1) was carried out prior to the active support training in the 5 months before the training commenced in each of the active support houses. Observations were also carried out in a non-active support house at about the same time. Observations included activities, social interactions and challenging behaviours using codes developed by Beasley et al. (1989). Minor challenging behaviours were typically stereotypical behaviours. Eleven hours observational data were collected between approximately 8.00 am and 7.00 pm in each house, divided into three sessions; 8.00 am to 12.00 noon, 12.00 until 4.00 pm and 4.00 pm until 7.00 pm, with clients being observed in rotation. These observations were spread over a number of days. Similar repeat observations (T2) of the houses were conducted approximately 4 weeks after interactive training had been completed.
Reliability data Inter-observer reliability for the direct observations was assessed by the presence of a second observer for two 1-h sessions in each of the six houses. Level of agreement was calculated for occurrence ⁄ non-occurrence of engagement in activity, social contact by staff, assistance and challenging behaviour using Cohen’s kappa. Kappa values for engagement, contact (neutral or positive), assistance and challenging behaviour were 0.69, 0.51, 0.21 and 0.73, respectively. As agreement about both contact and assistance was lower than desirable (Suen & Ary 1989), and assistance occurred throughout observations at a very low level, the two codes were combined to give a new composite code of contact ⁄ assistance, with a kappa value of 0.57. The term contact will be used throughout to describe contact and ⁄ or assistance.
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Table 4 Outline of workshop content Session
Outline
Principles and overview
Linking active support with service aims and philosophy and quality of life Providing an outline of the approach Explaining why active support is important in achieving service aims Discussing the consequences (for service users, staff and the service) of effective and ineffective engagement Discussing the importance of flexible planning Thinking about what is involved in the daily running of a house Discussion of service user current routine Identification of a core activity and support plan for the house for the week Discussion of how to use plans on a daily basis Discussing the importance of monitoring Suggesting ways of monitoring Demonstrating ways of using this information within the house Discussion of the use of prompts to increase participation specific to the person and situation Identification of prompts within tasks (task analysis) Consideration of positive reinforcement Problem solving (e.g. challenging behaviour, motivating someone to be involved, etc.) Writing plans in performance terms Importance of and identification of opportunities to target specific skills Discussion of ways of monitoring these opportunities Identification of opportunity plans for service users Discussion of ways of reviewing these opportunities within active support plans Importance of paying attention to maintenance issues Team work and consistency (e.g. handover periods, staff meetings) Reviewing the roles staff could play in this across the service (e.g. having active support on the agenda at all levels) Quality assurance Aims of interactive training and where this fits within active support Strengths and weaknesses of interactive training
Activity and support plans
Keeping track*
Providing support to promote participation
Writing clearly Opportunity planning
Maintaining quality*
Planning interactive training* *
Omitted from house C classroom-based training session. The practical components were omitted from other sessions, e.g. the team did not draw up an activity and support plan during the classroom-based session.
Results Individual client data are shown in Table 6 and overall data in Figure 1. Data were analysed by anova. Active support houses all showed increases in engagement (mean change from 16.6 to 26.0%), and comparison houses all showed decreases (mean change from 29.2 to 20.8%). The interaction between time and active support training was statistically significant (F1,19 ¼ 10.47, P < 0.01). The change in house C was statistically significant (F1,3 ¼ 26.55, P < 0.05). Active support houses all showed increases in staff contact (mean change from 16.7 to 21.2%), comparison houses showed decreases and increases (mean change from 16.2 to 13.1%). The difference between the two groups of houses was not statistically significant.
The correlation between changes in staff contact and user engagement (r ¼ 0.14) was not statistically significant. Active support houses all showed increases in challenging behaviour (mean change from 8.5 to 20.6%), and comparison houses showed decreases and increases (mean change from 21.6 to 17.3%). The overall interaction between time and active support training was statistically significant (F1,19 ¼ 5.59, P < 0.05).
Discussion On average, active support houses increased in activity, contact and levels of challenging behaviour. In comparison, non-active support houses showed an average decrease across all these measures. There was a significant increase in activity when all active support houses
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Table 5 Feedback given to staff pre- and post-interactive sessions House
Staff priorities pre-interactive session Increase positive reinforcement Recognize service user involvement in activity Use support strategies necessary to ensure service user success Create clear transitions Structure new activities Maintain present support strategies Reduce ⁄ alter use of prompts (verbal & physical) Increase client involvement in activities Reduce environmental distractions Lengthen tasks Increase preparation for activities Increase structure of tasks Increase use of modelling Increase physical support Feedback post-interactive session Good range of support strategies Clear transitions Positive tone and enthusiasm Good use of prompts (sensitive to the level of support required) Good use of positive reinforcement Good use of positioning Good preparation of activity Good task analysis Need to recognize and reward the small steps of service user involvement Need to increase structure within activities Need to improve preparation Need to organize new activities Need to minimize distractions Need to increase service user involvement Need to increase use of modelling Need to create clear transitions Need to increase awareness of service user understanding
A
B
C
1 1 0
3 2 4
2 2 0
0 2 1 5 4 4 1 2 0 0 0
1 3 2 0 0 0 0 0 0 0 0
1 0 2 0 0 2 0 6 4 2 1
0 1 4 6
5 1 4 4
7 0 8 9
6 2 1 1 2
0 0 0 0 4
0 0 4 0 0
0
4
0
0
0
8
3 3 4
2 0 0
0 0 0
0
0
5
0 3
0 0
2 0
were compared with all non-active support houses. In addition, activity levels for house C were found to have significantly increased following training. Engagement levels were on the whole low because of the level of
disability of the service users involved in the study. It is notable that levels of engagement found in studies of people with more severe learning disabilities have been lower than those we found (e.g. Emerson et al. 1999 found 11%). In houses A and B, activity levels increased for the two service users who were the most able (service users 5 and 21, respectively). In house C, activity levels increased for all service users. This may have been influenced by increased house manager involvement and team ownership, with managers and seniors conducting the interactive sessions with support from trainers. In addition, more attention was given to activity and shift planning. Finally, as a result of the delay in implementation of active support, house C had had more time to become established and settled in the community. However, if this were a major factor, it may be expected that T1 activity levels may have been greater, which is not the case. Anecdotal data suggested that house C staff were more skilled at working together as a team (and had more experience, more hospital experience and more nursing qualifications). While no conclusions can be drawn, these observations may be pertinent to the whole question of technology transfer – how can we ensure that services implement apparently effective ‘technologies’ such as active support? Whilst staff were supported to work with all service users throughout the interactive sessions, it may be that as those service users who were more able (and therefore had a higher initial degree of success when being supported to take part in activities) were more likely to be given opportunities to engage in activities. It is possible that this was an initial result of the training, whilst staff teams were becoming familiarized with the active support systems. It could be argued that supporting those service users who were less able required a greater degree of organization as well as greater degree of skill on the part of the staff. However, there are no data to support or challenge the suggestion that as staff teams became more familiar with active support, they would increasingly be able to engage people with more complex needs as T2 data was collected relatively soon after the implementation of active support. The overall increase in challenging behaviours for the active support houses was largely accounted for by increases in minor (e.g. stereotypical) rather than major challenging behaviours (e.g. physical aggression to property or other people, verbal aggression, smearing faeces, etc.). Major and minor challenging behaviours increased for client 7, despite relatively unchanged levels of activity and contact. For all other service users,
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Table 6 MTS data (%) for each service user Category Challenging behaviour Contact**
Activity
Major
Minor
House
Service user
T1
T2
T1
T2
T1
T2
T1
T2
A
5 6 7 1 3 4 8 15 21 13 16 17 22 18 19* 20 23 10 11 12 14
21.8 15.1 16.1 22.08 30.38 30.3 21.8 11.89 10.05 53.31 21.57 22.1 18.25 35.69 5.85 18.36 9.31 55.46 9.27 18.25 40.54
36.2 14.8 16.3 28.09 8.36 16.24 7.53 11.15 44.53 33.7 18.56 7.48 16.73 50.57 22.93 39.68 16.6 34.24 20.64 17.59 26.97
11.46 15.58 27.66 24.24 23.62 14.65 14.16 11.19 33.24 35.95 1.12 15.02 14.6 21.91 7.98 6.56 16.89 14.26 14.43 9.25 10.68
23.96 26.9 29.18 9.05 14.12 8.12 24.02 21.08 27.63 8.01 2.58 9.41 12.82 31.03 9.88 9.13 8.73 28.76 14.15 21.7 14.88
0.86 7.04 0 0 0 52.02 0.88 8.04 2.79 0.41 0 21.53 2.19 0 0 3.93 1.03 0.22 37.11 5 0.27
1.67 1.35 26.83 0.48 0 33.87 2.15 3.31 1.99 0 0.52 21.05 1.07 0 0.53 0 0.44 0 0.58 0 0
0 0 28.6 0 0 78.28 4.13 2.1 0.28 0 0.28 37.39 0 0 23.4 2.3 0 0 3.44 0 0
0 10.31 53.25 0 0 78.19 26.52 4.51 0 0 6.7 47.65 0 0 53.26 19.45 0 0 0 0 0
X
B
Y
C
Z
T1, pre-active support house receiving training; and T2, post-active support house receiving training. * Pre-active support training – 50% plus time in seclusion removed from analysis: service user 24 excluded from observations as no T1 data available. ** Used to describe contact or assistance.
% time
50 40
Activity
30
Contact
20
Challenging behaviour
10 0
T1 T2 Active Support Houses
T1 T2 Non-Active Support Houses
Figure 1 MTS data (%) showing overall levels in active support houses and nonactive support houses.
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major challenging behaviours remained unchanged or decreased. However, future research on active support should continue to monitor changes in challenging behaviour. In the current study, there were also increases in staff contact (including assistance) but the correlation between staff contact and individual client changes in engagement was weak (0.14) and non-significant. This may reflect either the confounding of contact and assistance in the measure or that some of the important changes in staff behaviour (e.g. planning of activities) were not picked up by the observational measure. Thirdly, increases in activity levels were accounted for (in houses A and B) by increases for the most able person in that house. This was typically the person needing least assistance to become engaged. For example, service user 21 needed to be provided with opportunities to take part in activities but did not necessarily need additional support to ensure successful participation. Staff reported that despite feeling apprehensive about interactive training sessions, they generally enjoyed them and felt that they gained confidence within the sessions to ‘try out’ activities. A range of priorities were given to staff of both pre- and post-interactive sessions (Table 3). There were some differences in the types of feedback given to each of the houses during the interactive training. This may reflect the biases of the trainers involved in the houses (not all trainers were involved in all houses) or reflect the strengths and needs of the staff and service users. In house C, feedback was given in a smaller range of categories than for the other two houses. This consistency across the training sessions may have been important in ensuring that key messages around the training were more likely to be picked up by the staff.
Conclusions Following the implementation of active support, activity levels were significantly increased, as has been found in previous research. Unlike previous research (Jones et al. 1999, 2001a,b; Felce et al. 2000), active support training was not found to have more benefit for less able service users and changes appeared unrelated to levels of staff contact. Active support training was associated with significant increases in (mainly minor) challenging behaviour. This draws attention to the importance of anticipating and managing this possible side-effect of active support. The change in the way in which active support was implemented may have resulted in improved results in house C. Important factors within this house may have
included the increased involvement of house managers and senior members of staff in delivering the training and increased ownership of the training. Further research is needed into the way in which interactive training is carried out, in particular with reference to the feedback given.
Acknowledgements The authors would like to thank all those involved in this project, particularly the staff and service users, East Kent Health Authority and the NHS Executive for funding the research and other participating Tizard Centre staff: Katy Arscott, Steven Carnaby, Jim Mansell, Glynis Murphy and Julie Nixon. Thanks also to Edwin Jones and The Welsh Centre for Learning Disabilities for the information, training materials and discussion on delivery and implementation of active support training.
Correspondence Any correspondence should be directed to Jill Bradshaw, Lecturer in Learning Disability (Honorary), Tizard Centre, University of Kent, Canterbury, Kent CT2 7LZ, UK (Tel.: 01227 764000; fax: 01227 763674).
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