Predictability can have a powerful impact on emotional wellbeing and we often feel safer when we have a sense of routine. For children and adults with severe and profound intellectual disability, having a sense of predictability and consistency can help to increase feelings of safety and security. Consistent, repeated routines can provide a sense of order and familiarity to the day and therefore create a sense of expectancy. Habitual behaviours and routines can act as cues for our body and mind to be able to predict and prepare for what is happening next. This can reduce stress, be reassuring and calming. Predictability may also help to modulate experience of pain. Cues to support an understanding of what is happening may therefore be particularly important if what is about to happen is going to be painful or distressing, such as with some medical interventions and meeting healthcare needs.
Our nervous system likes predictability. It is a system that looks for expectancy and when that is violated, it can go into a state of fear and hypervigilance. When this happens, the nervous system activates a stress response which leads to tightening of muscles, increased heart rate, and associated feelings of fear and anxiety. Repeated unfamiliar and unexpected situations can cause a repeated release of stress hormones, and therefore lead to the body being in a prolonged state of stress and anxiety. Along with chronic anxiety, symptoms of prolonged stress include headaches, trouble sleeping, digestive problems, muscle tension, and general aches and pains.
If we are exposed to stress in unpredictable and prolonged ways, our nervous system becomes overly active and reactive. This can affect all parts of the brain and body and negatively impact our emotional, physical, social and mental health. However, if we are exposed to stress in predictable, moderate and controllable ways, our nervous system develops a more flexible and manageable stress response and greater tolerance (Perry, 2021). Therefore, change can be ok, and indeed allows for new and exciting experiences, but needs to be predictable, moderate and controllable.
Establishing daily routines
Providing a regular routine can provide a sense of order to the day, and therefore can create a sense of expectancy – ‘knowing what is coming next’. Making sense of new environments, people, behaviours and experiences can be challenging for people with severe and profound learning disabilities. Organised, repetitive experiences can help the brain to make associations between what is happening and what will happen next.
For example, if a person’s morning routine consists of having a shower, getting dressed, eating breakfast, and this happens every day, through repetition of the same sequence, their brain may develop connections that enable awareness that after their shower, they will get dressed and whilst getting dressed they may begin to anticipate their breakfast as the next experience and so on.
Strategies and approaches for increasing consistency and expectancy
- Create and follow personalised routines
- Adopt consistent, personalised approaches throughout the team and across settings
- Have a named person or people responsible for giving care and support throughout the day, shift or session
- The named person can be in the same room or at the same table, even when they are busy doing other things so that they are present and available
- Use appropriate communication – e.g. on-body signing, objects of reference, sound, visual or scent cues
- Use identified and consistent cues, such as objects of reference or on-body signing, to signal the beginning and ending of activities.
- Repetition – e.g. engaging in repetitive behaviours, watching programmes, films, or playing the same game or singing the same song repeatedly
- Introduce change and new experiences slowly and gradually where possible and avoid sudden actions, sounds and abrupt movements that might be startling
- Ensure the person is in a position where it is easiest to sense what is going on around
- Approach from within the line of sight of the person so that you can be seen before making contact. If the person is visually impaired, be mindful of this in your approach. Use verbal prompts in a relaxed tone of voice to create an awareness that you are approaching. Use of soft touch such as gently holding a hand can provide reassurance.
- Support change and transitions (big and small), in easy phased steps, building on each step one by one once the person is comfortable enough to move on.
- Offer objects such as soft toys and twiddles to support transitions.
- Including this information in person-centred care, support and education plans and sharing it with others, as well as in documentation such as support, care and education plans may enable all involved to follow agreed routines and approaches, thereby enhancing consistency and expectancy. Including photographs can help in providing a visual understanding in addition to documentation.
Cross-setting consistency – Honest, open and positive communication across various settings such as home and day service, respite facility and school etc is essential in providing and maintaining consistency and routine. For example, if at home Mum uses a person’s coat as an object of reference for going outside, and in day service or school the staff use a hat, then consistency is lost, and the person is more likely to be confused.
Knowing and sharing knowledge of a person’s support plans can really help to establish consistency across settings. It can help to have an identified key person in each setting who knows the person well and has a clear understanding of their personalised routines and preferences. Regular cross-setting meetings with the person and their family can help maintain consistency. Communication notebooks or journals can also help to share and keep up to date with care, support and education plans. Meetings and open communication are especially important if the person is transitioning between classes at school or services. In this case, a clear step by step phased transition plan, is advised.
Consistency of people – Knowing people well and regularly spending time with them, enables us to tune into their means of communicating, their usual behaviours and responses. It helps us know what to expect from them in different situations. It also provides them with the opportunity to tune into us, and to interpret our individual behaviours and responses.
Consistency of people is very important in establishing stable and trusting relationships and maintaining predictability throughout daily interactions and routines. This is especially significant when a person’s means of communication may be complex and unique and may take time to tune into, get to know and understand. Therefore, having people around us who know us well can benefit self-esteem, a sense of belonging and safety.
Strategies for promoting predictability and consistency are explored in NAC’s course on Supporting Children and Adults with Severe and Profound Intellectual Disabilities Affected by Trauma Click here for more information.
Perry, B. and Winfrey, O. (2021) What Happened to You? Conversations on Trauma, Resilience, and Healing. Bluebird, London.
© Michelle Murphy RNID PGDip BSc
Senior Enhanced Nurse, Intensive Interaction Practitioner/Trainer
Julie Calveley, PhD, BSc(Hons) Psychology, Registered Nurse Learning Disabilities, NAC Director