Резюме. The topic of aggression is extremely relevant in our daily lives and this is why it is often the subject of theoretical and practical analysis. In the context of institutional care, it acquires specific dimensions related to a number of factors. This article presents two cases of residents of residential institutions for children and young people with disabilities, with an emphasis on influencing their level of aggressive response to reality. At the root of the interaction proposed are the ideas for supporting communication and for verbalizing desires and experiences in the context of group work. The cases described testify to the existence of positive tendencies in the ability to regulate one's own behaviour in the natural environment as well as in situations of provocation by others.

Ключови думи: children and young people with disabilities; institutionalization; aggressive behaviour; alternative communication; group work

Aggressive behaviour is an increasingly treated problem in the scientific and practical literature in our country. It is viewed in different planes, such as types, motives, participants, prevention, reduction, etc., with the main goal being to provide a more favourable environment for the development of the whole society. “Aggression is interpreted to a very wide extent and different accents are placed in its definition. But, in general, it can be defined as one of the possible forms of behaviour, which is activated in certain situations and characterized by deliberate violation of generally accepted norms of relationships and by harm to another person in order to achieve personal goals. Two factors are essential for an aggressive act: a situation in which it takes place and a person who performs the aggressive act” (Hristova-Kotseva, 2019: 121). In contrast to the classical definition of aggression according to which it has a conscious element of causing harm to another (Stamatov, 2000: 325), aggressive acts in the context of severe disabilities have a different meaning. Often, their basis is rooted in the underdeveloped level of functioning of thought processes, as a result of which the ability to interpret other people's behaviour and to make sense of one's own emotional world is affected. In parallel, there is weak control over the so-called volitional processes, which leads to difficult retention of impulses and to the need for instantaneous release of tension (Levterova-Gadzhalova, 2002: 176 – 177; Nazarova, 2000: 140 – 142; Georgieva, 2009: 36). All this gives rise to the idea of a different interpretation of aggression in people with multiple disabilities as a means of protection and satisfaction of needs rather than as a deliberate action.

Along with the personal characteristics of an individual, social components such as living conditions, parents’ attitudes, behaviour models of significant people, traumatic events, etc. have a direct influence on the formation of the aggressive response to the environment. These factors are essential in the growth of individuals with multiple disabilities as they can further aggravate their emotional world. In this regard, one of the critical groups at risk of developing aggressive strategies is inevitably that of children and young people with severe disabilities, deprived of parental care, and residing in social institutions.

A research on the difficulties in the daily life of the staff of residential institutions for children and young people with disabilities in Bulgaria found that the aggressive acts were second only to the difficulties in the self-service of the residents (Popova, 2017: 254). This gives grounds to assume a high level of aggressive and autoaggressive actions that lead to the establishment of a model of interaction based on pain and injury. A more detailed analysis of the reasons for such behaviour points to several main factors.

As already mentioned, the very state of many disabilities leads to specificity in the functioning of cognitive and volitional processes, which prevents the timely regulation of one's own behaviour. As a result, in response to insignificant external stimuli, the aggressive reaction - the most basic in the existence of any individual - takes place. However, there is additional dynamism in the state of the residents of an institution. In the first place, this is the fact that many of the persons accommodated in residential institutions have suffered numerous traumas in their lives related to a series of acts of “abandonment”. The initial abandonment by the parents is often followed by several transfers to different institutions, which reinforces the inner feeling of being unwanted. It, in turn, activates a number of unconscious fears. According to many proponents of the psychoanalytic interpretation of human behaviour, institutionalization, combined with the presence of a severe disability, leads to the formation of a psychotic or autistic personality structure (Roy, 2005; Cloutour, 2008; Lakadee, 2008). The essence of the psychotic structure directly corresponds to the formation of an aggressive response to the world, as it is based on the basic distrust of the other and the expectation of a threat from them. Thus, in residential institutions, the causes of aggression do not always have a visible expression as they are rooted in much deeper unconscious levels.

Along with such theories, considering the real living conditions in an institution where most of the individuals to communicate with have severe disabilities (with the residents outnumbering the staff), the idea of the emergence of conditions similar to induced delusional disorder (ICD-10, F24) can be derived. Induced delusional disorder is characterized by the presence of similar symptoms in people who are in close emotional relationships with individuals with disabilities. When they separate, a reduction in the symptoms is observed. Similarly, in residential institutions, there is an “infection” with aggressive acts in response to irritation. The level of development of cognitions makes it difficult to imitate a higher organization of activity, but allows it in more basic forms such as aggression.

The reasons described so far are only some of the reasons for the increased levels of aggression in residential institutions for children and young people with disabilities, but they are enough to show that such a problem really exists. In this regard, it is necessary to look for adequate methods for solution. Their importance should be linked to the possibility of “organizing a specific macro-social environment (interpersonal relationships, communication, etc.), preparing the formation of the social skill of “adaptability”, and ensuring adequate orientation and integration of children in the real socio-cultural conditions” (Konakchieva, 2017: 65).

Taking into account this reason as well as some additional research on the work of institutions, an experimental study was conducted in order to positively influence the residents’ behaviour. The study took 2 years and included theoretical analysis, experimental interaction, and analysis of the results. The experimental interaction was structured in regular classes for half a year, with included elements of supportive communication and models of verbalization of desires. The activities were conducted as a group, by a pre-prepared team that followed certain principles of communication with the residents. They contained suggestion of alternative behavioural reactions to increased tension, expressed by gestural and verbal responses. The aggressive acts during the group interaction were not tolerated and were worked out at the moment of their appearance.

In this article, we are presenting two cases that directly correspond to the problem of reducing aggressive behaviour.

Case Study 1

This case presents a 16-year-old male child residing at the time of the study in a family-type accommodation centre for children and young people with disabilities. The child was certified by TEMC with 99% reduced ability with assistance, with severe mental retardation as the main diagnosis and grand mal seizures, unspecified and cerebral cyst as concomitant diagnoses.

Personal history

The child's parents died. He has three brothers and two sisters who are younger than him, but does not keep in touch with his relatives. The child was placed in an institution 6 days after birth, followed by a period of upbringing in a family environment for 3 years (between his second and fifth year), after which he was placed in an institution for children with disabilities. He entered the Centre in 2015.

Profile based on a content analysis of the personal file:

The child is independent in activities such as dressing, eating, maintaining hygiene, taking care of personal belongings, cleaning. Needs to be reminded to do most of the activities. Observes the daily regime in the institution. Participates in the care for other residents. Without difficulties in the motor sphere. Memory and thinking are underdeveloped and highly dependent on his personal interests. Understands the speech of others. Oriented in directions and time. Recognizes the emotions of others. There are initial forms of mastering written speech. Initiates and maintains dialogue using speech at the level of sentences, gestures, and facial expressions. Having a poor vocabulary. Expresses his emotions with strong intensity, often with ascending gradation. When his desires are not satisfied, shows verbal and physical aggression and autoaggression. Does not respect social boundaries in communication. Has a tendency to show clinginess.

Results of the study of levels of aggression before and after the experimental interaction:

The results were obtained from structured interviews with the social worker of the institution and from direct observation in a natural environment. The data are presented in Table 1:

Information from direct observation during the experimental interaction:

The child participates in the proposed activities selectively, according to his current mood. In terms of implementation of the tasks set, he is rather passive, expects and seeks external help. Needs constant encouragement to finish what was started. Seeks the approval of all team members. Most of the time, answers the questions adequately, with a single word or simple, agrammatical sentences. Shows high initiative in communication and directs it mainly to adults. In the contacts with other children, there is strong suggestibility and he often uncritically follows their instructions or imitates their behaviour. During the first sessions, he showed increased levels of physical aggression directed at the other participants. It was mainly related to situations of intrusion into personal space or was instructed by another resident. After getting acquainted with and practicing the functional word “No”, no aggressive actions were registered until the end of the experimental interaction. The statistical processing of the observational data by using Kendall’s correlation between the trend in the change of aggression and the time shows a correlation value τB = -0.4, which is a statistically significant indicator at p <0.05.

Case analysis:

The data presented testify to some significant contradictions in the profile of the participant. First, there is a discrepancy between the medical diagnosis (Severe mental retardation) (ICD-10, F72) and the data on the levels of independence and development of cognitive processes. In this regard, the analysis was based on the skills and knowledge of the child and not on the specifics of the diagnosis. The second contradiction is the aggressive behaviour in everyday life. From the content analysis of the personal file, it is clear that the particular participant has an aggressive strategy for dealing with frustrating events, while the data from the interview with the social worker show no aggressive behaviour in a natural living environment. The objective observation at the beginning of the experiment supports the information obtained from the file. Given the specific characteristics of the child, namely his tendency to suggestibility and strong dependence on the opinion and support of adults, it can be supposed that in the presence of the social worker the participant will not show aggression due to his attitude to authority. Such a hypothesis would also provide an opportunity to explain the statistically significant difference in the indicator “aggression” at the beginning and the end of the experimental interaction, illustrated by the presentation of the data from the objective observation. At the beginning of the experimental interaction, the relationship between the residents and the interviewer (the latter carrying out the objective observation, too) was still unstable and built on short-term interaction. At the end of the experiment, the interviewer has already built authority in front of the participants, who became acquainted with the principles of work in classes, including not tolerating aggressive behaviour and providing an opportunity to verbalize (or gesture) desires or disagreements. Thus, the presence of the interviewer in the daily life of the participants led to the formation of principles of group work in the living environment. In parallel with this process, the strong need for approval of the specific resident could lead to a reduction of his aggressive behaviour.

Also of interest are the data obtained from the direct observation during the experimental interaction. The participant considered was the only one in whom there was a statistically significant reduction of aggressive behaviour over time during the classes. From the information presented above, the reduction of aggression occurred after the presentation and practicing of the functional word “No”, which allowed him to refuse to participate in the activities proposed. The nature of the proposed activities included the principle of non-violent involvement of the residents. Their participation was entirely voluntary, and presence in the workspace was allowed even without involvement in the tasks performed. The open statement of refusal and the compliance of the team therewith led to a decrease in the feeling of coercion. The child represented has an increased need for constant support in the performance of tasks and for approval by external authorities. This can be interpreted as lack of self-confidence, which gives rise to fearful experiences in any situation where something new needs to be done. Allowing an activity not to take place reduced the fear and consequently reduced the need for protection (aggressive in the case). Thus, the space of group work became for the child a space to satisfy his internal needs to be among people and to communicate without feeling pressure or frustration.

Case Study 2:

This case presents a 21-year-old woman living at the time of the study in a family-type accommodation centre for children and young people with disabilities. Her main diagnoses are legasthenia and common schizophrenia.

Personal history:

After birth, she was raised in a family environment until the age of 7. Due to the inability of the family to provide adequate care, she was placed in a home for children with mental retardation. Relocations to three other institutions followed. In 2015, she was accommodated in the family-type accommodation centre for children and young people with disabilities she lives in now.

Family history: her mother was diagnosed with epilepsy, her father was diagnosed with anxiety disorder with panic attacks, and her brother was diagnosed with oligophrenia. During the years of institutionalization, she did not keep in touch with her relatives.

Profile based on a content analysis of the personal file:

Independently dealing with the activities of eating, making her own toilet, and dressing. With assistance, deals with the activities of tidying up, cleaning, choosing the right clothes to put on. Observes the daily regime of the institution with assistance. There is fixation of attention on favourite things. In other cases, the concentration of attention is unstable. The functioning of her short-term memory is directly related to her interests. Long-term memory is chaotically organized. Thought process is inhibited. Speech is developed at the phrase level. Pronunciation and grammatical constructs are severely disturbed. Speech intelligibility is difficult. Initiates communication on topics related to her interests. Understands basic conversation and instructions. Uses natural gestures. Finds it difficult to respect personal space and differentiate between role partners (peers and adults). Her volitional behaviour is related to her interests and immediate desires. Controls her emotional states with help. Shows aggression when personal space is violated. Aggression is directed at other residents and household items. When expressing desires, there is an echolalic copying of the behaviour of the nonverbal residents.

Results of the study of the levels of aggression before and after the experimental interaction:

The results were obtained from structured interviews with the social worker of the institution and from direct observation in a natural environment. The data are presented in Table 2:

Information from direct observation during the experimental interaction:

Takes selective part in the activities proposed. Demonstrates refusal mainly by behavioural manifestations: getting up and leaving the room, making gestures without a clear meaning. Over time, the refusal became more and more verbal: “No”, “I do not want to”, “I will not”. Responds to verbal contacts with a verbal response consisting of a single word or phrase. There were situations of refusal of a verbal response and preference for a behavioural reaction: touching parts of her face, gestures. In the first sessions, there was a passive implementation of the activities set. Gradually, self-initiated involvement in activities related to enhanced sensory (mostly tactile) experiences was observed. In the beginning, she initiated a conversation with the team only on topics important to her, which were not in the context of what was happening. Initiates a conversation with other residents in situations where she is very impressed by their behaviour. Over time, the topics were enriched and went beyond her personal fixations. Starts a discussion on current activities and comments on residents’ behaviour. Needs physical support in completing the activities which gradually turned into verbal. There were several situations in the second half of the interaction, in which she performed the tasks independently. Aggressive manifestations were observed in situations of violation of personal space and in response to the aggression of other residents. Has a low tolerance threshold; her reactions are impulsive, mainly in the form of physical aggression. In the last sessions of the experimental interaction, there were verbal responses accompanied by the studied gesture “Stop”. The verbal responses contained a request to stop the action and share the experiences: “Stop this! I do not like it!”.

Case analysis:

The information obtained on the case from the interviews and the observations in a natural environment and in classes reveals some specific features of the participant. There is a fixation on certain topics, which hinders the adequate communication. Behavioural models are mostly used despite the somewhat developed verbal skills. Aggressive models for dealing with threats (intrusion into personal space) were established.

The content data obtained during the experimental interaction indicate an increase in the verbal responses and broadening of the conversation topics. Particularly impressive is the verbalization of the message and feelings in situations of provocation by other participants. Depending on the characteristics of the proposed activities, several hypotheses can be raised about the occurrence of such changes.

First, the sequence of actions in the communicative act presented in the study of functional words gives the participant a clear and accessible idea of the nature of communication as a mutual process of alternating the roles of the speaker and the listener (performer). Repeated behavioural training of these roles leads to improved listening skills, respectively patience, which gives the mind time to process the information provided and to structure the speech. Thus, the quality of communication acquires greater focus and commitment to the context of the topic discussed. One of the indicators of full development is the ability to establish relationships with other people and make verbal contacts on an emotional basis. By mastering speech models of communication, a participant seeks to respond adequately to the situation, builds a strategy, follows a certain discourse, and achieves their communicative intentions which are mediated by interaction with the social environment (Chuhovska, 2016).

Of course, given the existing disabilities and the family history revealed in the content analysis of the resident’s file, the expectations for development of the communication skills should be realistic, i.e. minimal success should be sought over a longer period of time. In this sense, the observed increase in cases of verbal response at the expense of cases of behavioural response can be considered as an extremely important and significant change in behaviour.

The second aspect that could be analysed as a means of change support is the provision of variability in communication: words, gestures, symbols. Despite the partially developed verbal skills, the participant uses mainly behavioural models in her communication. Offering a regulated behavioural model in the form of gestures serves this need of hers. On the other hand, as can be seen from the personal file, there is a developed ability to use natural gestures. The combination of this skill and the targeted training to incorporate new gestures, along with the speech, expands the potential abilities in appropriate situations. This leads to situations in which the participant manages to transfer the ability to use the gesture and the word “Stop” from the artificially created learning environment into the natural interaction with other residents. The gesture in this case plays a supporting role, but without it the speech may not be well and adequately structured. It is the trigger of the words through which the desire is stated and the reason is substantiated.

The cases presented illustrate some of the opportunities that alternative and complementary communication as well as a clear structure give to children and young people with severe disabilities. In the context of institutional care, it is extremely difficult to influence the aggressive response of residents to the environment due to its deep, unconscious roots caused by a number of aggravating factors. In this sense, it is extremely important that the aggressive behaviour in such an environment be interpreted in absolute dependence on the individual characteristics of the individuals, their personal history, the nature of the disability, their interests, difficulties, and resources. Thus, the search for methods and techniques for influencing becomes a serious analytical process mixed with knowledge of sufficient theoretical statements and shared experience. The proposed model of group work including acquaintance with the nature and meaning of the communicative act and the introduction of auxiliary communication tools provides an affordable option for the real conditions of residential institutions. However, in order to implement it in everyday life, good staff training, good knowledge of the needs of children and young people, and specialized support of both parties in this complex process are needed.

NOTES

1. International Statistical Classification of Diseases and Related Health Problems 10th revision (ICD-10) (2003). Vol. 1, WHO, Geneva.

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