Term Challenging Behaviour

Categories: Disorder Learning Disabilities Psychology

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The term `challenging behaviour' is now more commonly used and has replaced previous terms such as ‘problem behaviour’ or ‘behaviour disorder’. The reasoning is that it reflects a view that the problem is not a property of the behaving person but emerges from how the behaviour is perceived, managed and tolerated by other people. The intensity of the challenge depends not only on the nature of the behaviour but also on the skills of the carers and others in their abilities to respond to the behaviour with a view to lessen or discourage the impact of the behaviour (Emerson and McGill et all.,1994).

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The existence of CB in people suffering with a learning disability can have serious detrimental consequences in their quality of life Lowe et al. (1995:595 cited in Abudarham and Hurd, 2002).

As a result of the behaviour there is a likelihood that this will limit or impact on access to ordinary community services or in the extreme deny access or the use of that service. This definition was further amended by Emerson (1995, cited in Abudarham and Hurd, 2002) to include ‘culturally abnormal behaviour(s)’ which highlighted the significance of considering cultural and social norms. CB’s can be loosely divided or categorised into behaviours that are either ‘outer directed’ or ‘inner directed’. An example of outer directed behaviour could include showing or being aggressive towards another person, whilst inner directed can include self-injurious behaviour to one-self which can include self-harming with implements, head banging, burning one-self, eating and swallowing objects or matter.

The study undertaken by Lowe and Felch (1995, cited in Abdurham and Hurd, 2002) highlighted that the behaviours the posed the most problems included aggressiveness, disturbing noises, wandering away, sexual delinquency and temper tantrums. Other behaviours that did not pose equivalent challenges or serious management problems include withdrawal, inactivity or stereotypical behaviours. Self-injuries behaviour was defined by Murphy and Wilson (1985, pg. 15) as “Any behaviour, initiated by the individual which directly results in physical harm to that individual. Physical harm includes bruising, lacerations, bleeding, bone fractures, breakages and other tissue damage.” NICE Guidelines (2013) define self-harm as “self-poisoning or self-injury, irrespective of the apparent purpose of the act.”

Peter’s challenging behaviour is inner-directed as he feels that it alleviates the tension and anxiety issues he is suffering from. Causes of self-harm may be triggered by family issues, relationship break up, history of sexual, mental and physical abuse. An act of self-harm is often described by service users as a coping mechanism and a distraction that may bring relief. In most cases it will bring on feelings of disgust and shame (Chapman et al., 2006). The World Health Organisation (WHO, 2013) evidence base recommendations for management of self-harm includes removing the means of self-harm, regular contact with the person who is self-harming, adopt a problem solving approach, provide social support, hospitalization for person who self-harms, reducing access to the means of the suicide, reducing the availability of drugs and alcohol and responsible media reporting. In order to support Peter appropriately a functional assessment needs to be undertaken which will enable me to form an educated guess/hypotheses as to why Peter engages in this behaviour.

When undertaking a functional assessment the aim is to capture pertinent information in all of the environments and situations where the behaviour occurs. By conducting it in this manner it may elevate the ecological validity of the resulting assessment data and also increase the possibility that the assessment results will capture the range of antecedents and consequences that are influencing the person to behave in that manner ( Sigafoos and Arthur et al., 2003). The functional assessment can be sub-divided or categorised into an indirect assessment method or a direct assessment method. The indirect assessment method include rating scales and interview methods due to the fact it does not require direct observation when the person is presenting with the CB. The direct assessment method entails systematically observing the person engaging in the challenging behaviour and recording the occurrence/non-occurrence of that challenging behaviour (Sigafoos and Arthur et al., 2003)

Interviews and rating scales when referring to indirect assessments are reliant on subjective verbal reports by a third party to identify the type of CB, the causal factors and the environmental conditions that are controlling it. When conducting interviews it is imperative for successful analysis that persons interviewed are in daily contact with the person so they can best describe historical events that have occurred and they have been witness to and from this formulate a conclusion of the causal factors of the individual’s behaviour (Sigafoos and Arthur et al., 2003). The three main objectives of the behavioural interview are to establish the description of the behaviour(s) (i.e. type of problem and it’s appearance), identifying the physical and environmental factors that seem to forecast the challenging behaviour (i.e. occurrence or time of the behaviour) and identifying the maintaining consequences (consequential events that are functioning as reinforcers as a result of the behaviour).

Therefore for best practice the interview should entail probes that are specific in identifying features of the CB, in which circumstance the behaviour occurs or does not occur and the reactions of persons in the immediate environment when witnessing the CB (Sigafoos and Arthur et al., 2003). Gardner et al. (1986, cited in Sigafoos and Arthur et al., 2003) developed the ‘Setting Event Checklist’ which is an example of an indirect assessment and proves useful in identifying the influence of global antecedent conditions. This tool consists of questions about the physical condition of the person, their mood and the precipitating factors for social interactions. It also entails the dubiety on how recent the conditions or interactions occurred. Example questions within this checklist aim to identify whether the person presenting with the CB was informed of a change in conditions than their norm, are they tired and suffering from lethargy or have they been assigned new to oversee their care and they are unfamiliar with.

There are other indirect assessment tools which are useful to use for practitioners to identify the potential consequences in maintaining CB. These include the Motivation Assessment Scale (MAS) which was created by Durrand and Crimmins (1986) and has a series of 16 questions which aim to establish and help the practitioner in determining whether the behaviour is related to attention, escape, tangible or sensory. Others include the Questions About Behavioural Function (QABF) by Paclawskyj et al., (2000) and the Behaviour Diagnostic form created by Bailey and Piles (1989). When undertaking the various indirect assessments it is of paramount importance that practitioners endeavour to get answers to four key questions about the behaviour.

These are in which condition does it occur or most frequently occur, are there times when it rarely or never occurs, establishment of events and interactions that are in occurrence when the behaviour begins and what can be implemented to stop the behaviour ( Sigafoos and Arthur et al., 2003). Direct functional assessments entails methodically observing the person engaged in the CB and documenting the occurrence/non-occurrence of the CB. There are various different direct observational methods and these include ‘Scatterplot Assessments’, ‘Antecedent Behaviour Consequence (ABC)’ and the Functional Analysis. The information gained from these assessments varies in nature and is dependent on the person’s ability whom is conducting the assessment, the time and effort that is needed to conduct such observations and clarification of what exactly is to be observed (Sigafoos and Arthur et al., 2003). When conducting the various direct assessments it is important to translate these into observable behaviours before commencing the observation.

The reasons being that it allows for more reliable observations, provides clarity of the behaviour that needs changing and lastly it allows throughout the intervention process an evaluation of the CB. If the desired outcome is not achieved then the type of intervention can be adapted or changed to reach the desired goal. The next step when consensus is agreed on what is to be observed the use of ‘Scatterplots’ and ‘ABC’ assessment. These tools enable the practitioner to observe the person during their regular daily routines and note when the CB is most prevalent. In addition to this the practitioner can systematically structure the environment and measuring the accompanying changes in behaviour (Sigafoos and Arthur et al., 2003). Scatterplot assessments have been described by Touchette et al. (1985, cited in Sigafoos and Arthur et al., 2003) as probably the easiest direct observation method.

This method allows the practitioner to identify during the day when the behaviour occurs but is designed not to identify the precursors that evoke or motivate the CB and should be used in conjunction with indirect assessment methods to formulate a hypothesis as to why the person in engages in CB. Scatterplots can also be used as pre assessment tool identify when CB occurs and make allowances for a detailed assessment at high frequency periods of CB (Sigafoos and Arthur et al., 2003). The design of the Scatterplot is simple in nature and entails time periods on the vertical axis and days on the horizontal axis. The time segments can also be shortened/widened to suit a particular situation. Once the Scatterplot is completed it enable the practitioner to identify visually when high and low risk situations occur.

The ‘Antecedent Behaviour Consequence (ABC)’ tool enables the practitioner to observe behaviour over a period of time and a description of the type of behaviour is recorded. Within the recorded description there are the antecedents and consequences of that behaviour and what the person done in each instance, followed by a description of what was occurring when the behaviour initiated. The format of this tool entails the number of instances that occurred, what was happening at the time, what behaviour was perceived as a problem and what happened in response to the behaviour. The observer needs to be adept and significant effort and time needs to be allocated to formulate a clear picture of the CB. If there are time constraints placed upon the practitioner and other duties need to be undertaken within their role the practitioner can use a scatterplot to determine when the situation/behaviour occurs most frequent and then undertake the ABC tool when the behaviour is most prevalent.

It is good practice that at least 20 occurrence’s need to be recorded before attempting to interpret the results of the ABC analysis as this may allow the practitioner to see some sort of pattern (Sigafoos and Arthur et al., 2003). The ‘Functional Analysis’ devised by Iwata et al. (1982; 1994 cited in Sigafoos and Arthur et al., 2003) entails examining the person’s CB under a number of predetermined social conditions which are constructed in a manner for the purpose of identifying specific consequences that are maintain the CB. The number of conditions can vary but usually there are four. The contents are determined on an individual basis which have been sourced from previous interviews and observations. In this section there will be an exploration of the key drivers in the CB arena which endeavour to provide equitable treatment to persons with challenging behaviours. Professor Jim Mansell has achieved great accolades nationally as well as respect in the field of learning disability and community care.

He is the founder director of the ‘Tizard Centre’ which has been recognised as one of the world’s leading centres of study within this field and has published numerous research papers as well as influential guidance on Services for People with Learning Disabilities and Challenging Behaviour or Mental Health Needs (1993) which was subsequently revised in 2007 and are popularly known as the “Mansell Reports” (The Challenging Behaviour Foundation, 2008). He also written a report on services for adults with profound and multiple learning disabilities (PMLD) and was called ‘Raising Our Sights (2010). The report entailed good practice within services but also highlighted bad practice. The personalisation agenda was included as well as 33 recommendations across areas such as health, wheelchairs, assistive technologies and day activities (Mencap, 2010)

The Valuing People Now document is a three year strategy for people with learning disabilities and particularly sets out to address what people have told the government about the type of support needed for people with learning disabilities and their families. This document also takes into account and reflects the changing priorities which have a direct impact and sets out the government’s response to the ten recommendations in the ‘Healthcare for All’ (2008, cited in Department of Health, 2009) report which was an independent inquiry chaired by Sir Jonathan Michael into access to healthcare for people with learning disabilities. Lastly, it provides a further response to the joint committee on human rights report ‘A Life Like Any Other?’ (2008, cited in Department of Health, 2009) report that concluded that adults with learning disabilities are particularly vulnerable to breaches of their human rights.

The vision and key messages in this document remain the same as set out in the Valuing People (2001, cited in Department of Health, 2009) document. Within the document it mentions that people with learning disabilities are entitled to the same rights and choices as anybody else, have the right to be treated with respect and dignity, have the same chances and responsibilities as everyone else and family carers and families of people with learning disabilities have the right to same hopes and choices of other families. The new strategy entails key components that further strengthen its commitments to people with learning disabilities and is now more inclusive of a multitude of people whom were least often heard and most often excluded. Examples include the Black Minority Ethnic (BME) groups, people with complex needs, offenders whom were incarcerated or in the community and people suffering from autistic spectrum disorders (Department of Health, 2009).

The ‘Personalisation’ component in the strategy aims to give more choice, control and independence and is geared towards enabling people with learning disabilities to get a say on what treatment or care they need, be allowed to plan how the money is spent on the care and be able to choose who they want to support them and how (Department of Health, 2009). ‘Having a life’ within the strategy touches on the fundamentals that the same opportunities/choices apply to people with learning disabilities and they should receive healthcare that is not inferior to that of people without a learning disability, have a right to choose their housing provision, have same opportunities to education, training and employment and to form relationships and raise a family. ‘People as citizens’ within the strategy includes advocacy provision, better accessibility for transport, opportunities for leisure and social activities, being safe in the community or at home and access to justice and redress (Department of Health, 2009).

The ‘Making it happen’ component entails working in partnership with organisations within this arena to make this a reality for people with learning disabilities. The government is to continue supporting organisations such as ‘The National Forum for People with Learning Difficulties’ and ‘The National Valuing Families Forum’ (Department of Health, 2009). The ‘Putting People First’ government report identifies a shared vision for change within the adult social care arena. The report entails the key challenges that the government is facing which include increasing demographic pressure as people are living longer and may experience more complex conditions as they get older, the change in family structures and how this impacts on families, the changing of expectations and the increasing choice which this demands and financial pressures.

The key themes within this report are ‘Choice and Control’, ‘Universal Services’ & ‘Social Capital’, ‘Early Intervention & Prevention’ and ‘Market Shaping’ (Department of Health, 2007). The term `challenging behaviour' is now more commonly used and has replaced previous terms such as ‘problem behaviour’ or ‘behaviour disorder’. The reasoning is that it reflects a view that the problem is not a property of the behaving person but emerges from how the behaviour is perceived, managed and tolerated by other people. The intensity of the challenge depends not only on the nature of the behaviour but also on the skills of the carers and others in their abilities to respond to the behaviour with a view to lessen or discourage the impact of the behaviour (Emerson and McGill et all.,1994). The existence of CB in people suffering with a learning disability can have serious detrimental consequences in their quality of life Lowe et al. (1995:595 cited in Abudarham and Hurd, 2002).

The definition of CB by Emerson (1987, cited in Abudarham and Hurd, 2002) describes it as a behaviour coupled with high intensity and frequency with a propensity to seriously jeopardise the physical safety of the person and others. As a result of the behaviour there is a likelihood that this will limit or impact on access to ordinary community services or in the extreme deny access or the use of that service. This definition was further amended by Emerson (1995, cited in Abudarham and Hurd, 2002) to include ‘culturally abnormal behaviour(s)’ which highlighted the significance of considering cultural and social norms. CB’s can be loosely divided or categorised into behaviours that are either ‘outer directed’ or ‘inner directed’. An example of outer directed behaviour could include showing or being aggressive towards another person, whilst inner directed can include self-injurious behaviour to one-self which can include self-harming with implements, head banging, burning one-self, eating and swallowing objects or matter.

Lowe et al views on challenging behaviours (1995, cited in Abdurham and Hurd, 2002) reports that CB by definition be-sets both types of behaviour (due to them being defined by ‘consequence’ rather than ‘form’), however evidence gathered from referrals for specialist treatment indicate they are made for people presenting with behaviours that are a disruption to the environment, rather than those that hinder or interfere with the persons learning potential. The study undertaken by Lowe and Felch (1995, cited in Abdurham and Hurd, 2002) highlighted that the behaviours the posed the most problems included aggressiveness, disturbing noises, wandering away, sexual delinquency and temper tantrums. Other behaviours that did not pose equivalent challenges or serious management problems include withdrawal, inactivity or stereotypical behaviours.

Self-injuries behaviour was defined by Murphy and Wilson (1985, pg. 15) as “Any behaviour, initiated by the individual which directly results in physical harm to that individual. Physical harm includes bruising, lacerations, bleeding, bone fractures, breakages and other tissue damage.” NICE Guidelines (2013) define self-harm as “self-poisoning or self-injury, irrespective of the apparent purpose of the act.” Peter’s challenging behaviour is inner-directed as he feels that it alleviates the tension and anxiety issues he is suffering from. Causes of self-harm may be triggered by family issues, relationship break up, history of sexual, mental and physical abuse. An act of self-harm is often described by service users as a coping mechanism and a distraction that may bring relief. In most cases it will bring on feelings of disgust and shame (Chapman et al., 2006).

The World Health Organisation (WHO, 2013) evidence base recommendations for management of self-harm includes removing the means of self-harm, regular contact with the person who is self-harming, adopt a problem solving approach, provide social support, hospitalization for person who self-harms, reducing access to the means of the suicide, reducing the availability of drugs and alcohol and responsible media reporting. In order to support Peter appropriately a functional assessment needs to be undertaken which will enable me to form an educated guess/hypotheses as to why Peter engages in this behaviour. When undertaking a functional assessment the aim is to capture pertinent information in all of the environments and situations where the behaviour occurs. By conducting it in this manner it may elevate the ecological validity of the resulting assessment data and also increase the possibility that the assessment results will capture the range of antecedents and consequences that are influencing the person to behave in that manner ( Sigafoos and Arthur et al., 2003).

The functional assessment can be sub-divided or categorised into an indirect assessment method or a direct assessment method. The indirect assessment method include rating scales and interview methods due to the fact it does not require direct observation when the person is presenting with the CB. The direct assessment method entails systematically observing the person engaging in the challenging behaviour and recording the occurrence/non-occurrence of that challenging behaviour (Sigafoos and Arthur et al., 2003) Interviews and rating scales when referring to indirect assessments are reliant on subjective verbal reports by a third party to identify the type of CB, the causal factors and the environmental conditions that are controlling it.

When conducting interviews it is imperative for successful analysis that persons interviewed are in daily contact with the person so they can best describe historical events that have occurred and they have been witness to and from this formulate a conclusion of the causal factors of the individual’s behaviour (Sigafoos and Arthur et al., 2003). The three main objectives of the behavioural interview are to establish the description of the behaviour(s) (i.e. type of problem and it’s appearance), identifying the physical and environmental factors that seem to forecast the challenging behaviour (i.e. occurrence or time of the behaviour) and identifying the maintaining consequences (consequential events that are functioning as reinforcers as a result of the behaviour). Therefore for best practice the interview should entail probes that are specific in identifying features of the CB, in which circumstance the behaviour occurs or does not occur and the reactions of persons in the immediate environment when witnessing the CB (Sigafoos and Arthur et al., 2003).

Gardner et al. (1986, cited in Sigafoos and Arthur et al., 2003) developed the ‘Setting Event Checklist’ which is an example of an indirect assessment and proves useful in identifying the influence of global antecedent conditions. This tool consists of questions about the physical condition of the person, their mood and the precipitating factors for social interactions. It also entails the dubiety on how recent the conditions or interactions occurred. Example questions within this checklist aim to identify whether the person presenting with the CB was informed of a change in conditions than their norm, are they tired and suffering from lethargy or have they been assigned new to oversee their care and they are unfamiliar with. There are other indirect assessment tools which are useful to use for practitioners to identify the potential consequences in maintaining CB.

These include the Motivation Assessment Scale (MAS) which was created by Durrand and Crimmins (1986) and has a series of 16 questions which aim to establish and help the practitioner in determining whether the behaviour is related to attention, escape, tangible or sensory. Others include the Questions About Behavioural Function (QABF) by Paclawskyj et al., (2000) and the Behaviour Diagnostic form created by Bailey and Piles (1989). When undertaking the various indirect assessments it is of paramount importance that practitioners endeavour to get answers to four key questions about the behaviour. These are in which condition does it occur or most frequently occur, are there times when it rarely or never occurs, establishment of events and interactions that are in occurrence when the behaviour begins and what can be implemented to stop the behaviour ( Sigafoos and Arthur et al., 2003).
Direct functional assessments entails methodically observing the person engaged in the CB and documenting the occurrence/non-occurrence of the CB.

There are various different direct observational methods and these include ‘Scatterplot Assessments’, ‘Antecedent Behaviour Consequence (ABC)’ and the Functional Analysis. The information gained from these assessments varies in nature and is dependent on the person’s ability whom is conducting the assessment, the time and effort that is needed to conduct such observations and clarification of what exactly is to be observed (Sigafoos and Arthur et al., 2003). When conducting the various direct assessments it is important to translate these into observable behaviours before commencing the observation. The reasons being that it allows for more reliable observations, provides clarity of the behaviour that needs changing and lastly it allows throughout the intervention process an evaluation of the CB. If the desired outcome is not achieved then the type of intervention can be adapted or changed to reach the desired goal.

The next step when consensus is agreed on what is to be observed the use of ‘Scatterplots’ and ‘ABC’ assessment. These tools enable the practitioner to observe the person during their regular daily routines and note when the CB is most prevalent. In addition to this the practitioner can systematically structure the environment and measuring the accompanying changes in behaviour (Sigafoos and Arthur et al., 2003). Scatterplot assessments have been described by Touchette et al. (1985, cited in Sigafoos and Arthur et al., 2003) as probably the easiest direct observation method. This method allows the practitioner to identify during the day when the behaviour occurs but is designed not to identify the precursors that evoke or motivate the CB and should be used in conjunction with indirect assessment methods to formulate a hypothesis as to why the person in engages in CB. Scatterplots can also be used as pre assessment tool identify when CB occurs and make allowances for a detailed assessment at high frequency periods of CB (Sigafoos and Arthur et al., 2003). The design of the Scatterplot is simple in nature and entails time periods on the vertical axis and days on the horizontal axis. The time segments can also be shortened/widened to suit a particular situation.

Once the Scatterplot is completed it enable the practitioner to identify visually when high and low risk situations occur. The ‘Antecedent Behaviour Consequence (ABC)’ tool enables the practitioner to observe behaviour over a period of time and a description of the type of behaviour is recorded. Within the recorded description there are the antecedents and consequences of that behaviour and what the person done in each instance, followed by a description of what was occurring when the behaviour initiated. The format of this tool entails the number of instances that occurred, what was happening at the time, what behaviour was perceived as a problem and what happened in response to the behaviour. The observer needs to be adept and significant effort and time needs to be allocated to formulate a clear picture of the CB. If there are time constraints placed upon the practitioner and other duties need to be undertaken within their role the practitioner can use a scatterplot to determine when the situation/behaviour occurs most frequent and then undertake the ABC tool when the behaviour is most prevalent.

Professor Jim Mansell has achieved great accolades nationally as well as respect in the field of learning disability and community care. He is the founder director of the ‘Tizard Centre’ which has been recognised as one of the world’s leading centres of study within this field and has published numerous research papers as well as influential guidance on Services for People with Learning Disabilities and Challenging Behaviour or Mental Health Needs (1993) which was subsequently revised in 2007 and are popularly known as the “Mansell Reports” (The Challenging Behaviour Foundation, 2008). He also written a report on services for adults with profound and multiple learning disabilities (PMLD) and was called ‘Raising Our Sights (2010). The report entailed good practice within services but also highlighted bad practice.

The personalisation agenda was included as well as 33 recommendations across areas such as health, wheelchairs, assistive technologies and day activities (Mencap, 2010) The Valuing People Now document is a three year strategy for people with learning disabilities and particularly sets out to address what people have told the government about the type of support needed for people with learning disabilities and their families. This document also takes into account and reflects the changing priorities which have a direct impact and sets out the government’s response to the ten recommendations in the ‘Healthcare for All’ (2008, cited in Department of Health, 2009) report which was an independent inquiry chaired by Sir Jonathan Michael into access to healthcare for people with learning disabilities. Lastly, it provides a further response to the joint committee on human rights report ‘A Life Like Any Other?’ (2008, cited in Department of Health, 2009) report that concluded that adults with learning disabilities are particularly vulnerable to breaches of their human rights.

The key themes within this report are ‘Choice and Control’, ‘Universal Services’ & ‘Social Capital’, ‘Early Intervention & Prevention’ and ‘Market Shaping’ (Department of Health, 2007). In concluding this assignment it is important to note that various assessment methods and questions can be used and asked to form a hypothesis on Peter’s behaviour. It also is useful to focus on the antecedents and the consequences that may conjure and maintain his behaviour. The Scatterplot’ and the ‘ABC’ analysis were consistent with that of the indirect assessments enabling me to be more confident in formulating a judgement on the function or purpose of Peter’s self-harm. The key drivers mentioned in this assignment have made significant inroads in achieving fair and equitable treatment for people with CB, learning disabilities and mental health problems. In undertaking this assignment my knowledge on CB has immensely improved and now feel confident that the knowledge gained from this assignment can be applied and incorporated into my working practice.

In concluding this assignment it is important to note that various assessment methods and questions can be used and asked to form a hypothesis on Peter’s behaviour. It also is useful to focus on the antecedents and the consequences that may conjure and maintain his behaviour. The Scatterplot’ and the ‘ABC’ analysis were consistent with that of the indirect assessments enabling me to be more confident in formulating a judgement on the function or purpose of Peter’s self-harm. The key drivers mentioned in this assignment have made significant inroads in achieving fair and equitable treatment for people with CB, learning disabilities and mental health problems. In undertaking this assignment my knowledge on CB has immensely improved and now feel confident that the knowledge gained from this assignment can be applied and incorporated into my working practice.