An overview of the included systematic review can be found in Table 144. A search for other systematic reviews identified only 1: Heyvaert 2014 ( Heyvaert et al., 2014). No RCTs or systematic reviews of RCTs met the eligibility criteria for this review. However, the focus has continued to be on the principles of least restrictive alternatives, proportionality to the risks posed by the behaviour and gradient approaches to any reactive or restrictive interventions, considering restrictive interventions only as a last resort. Guidance issued on the subject of behavioural support, reactive strategies and restrictive practices has taken on a generic health and social care focus where previously specific guidance for people with a learning disability and behaviour that challenges was published ( Paley, 2013). Traditional behaviour support planning typically draws on a menu of reactive strategies including: environmental change stimulus control, cessation or introduction preferred activities preferred interactions/people distraction, diffusion and de-escalation. Reactive strategies are more likely to be effective in the context of good person-centred planning that recognises the situations, environment, social settings or interpersonal environments that are associated with a higher likelihood of behaviour that challenges and seeks to affect change in those settings. Such approaches treat people with dignity and respect, have an ethical basis and are delivered alongside proactive strategies in order to reduce the likelihood of behaviour that challenges. More recently interventions that focus on upholding an individual's human rights have come to the fore. Much research in the 1970s and 1980s focused on alternatives to punishment and aversive strategies. Reactive strategies do not aim to achieve long-term behaviour change, however those strategies that are aversive or punitive have the potential to change an individual's behaviour through negative association with displaying particular behaviours. It is suggested that up to half of people with a learning disability who display behaviour that challenges may be subject to reactive strategies ( Paley, 2013). Reactive strategies may take a number of forms and can include environmental, psychosocial and restrictive interventions such as physical holds, mechanical and manual restraint, seclusion and ‘time out’ or the use of emergency medication. Reactive strategies have the aim of bringing about immediate behavioural change in an individual or establishing control over a situation so that risk associated with the presentation of the behaviour is minimised or eradicated. Reactive strategies are actions, responses and planned interventions in response to the presentation of identifiable behaviour that challenges.
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