Care & Support Services - Achieving Best Practice

Challenging behaviour

Understanding and responding to challenging behaviour

Challenging behaviour describes a range of difficult and disturbed actions. Individuals displaying challenging behaviour need support from a team of carers, each with a different role to ensure the individual's needs are met.

Judgements on challenging behaviour are made on assessments that consider current and past life experiences and direct observations (e.g. how the individual handles different situations).

'Challenging behaviour' is a description that can be given to a whole range of behaviours and their presented difficulties. It is usually used in reference to individuals who are showing some form of difficult or disturbed behaviour. Such descriptions are sometimes applied too readily and more casually than they should be. Essentially, the term should only relate to a range of difficulties which are professionally described, analysed and assessed. Difficulties to which some form of support plan has been, or is being, devised.

General comments regarding challenging behaviour

There is a risk that people see behaviour which they don't understand - which can appear meaningless, disruptive, aggressive and even self-injurious - as a personal problem of the individual. They may consider that the word 'challenging' relates to a purposeful act by the person to be disruptive. This must not be the case. The 'challenge' is essentially for a service or others to try and understand why an individual needs to behave in the way that they do. This 'challenge' concept puts the emphasis and responsibility on all organisations, carers or professionals to respond with a constructive solution to the difficulties. It should remove the notion of the difficult behaviour being an innate feature of an individual which they carry around as an essential part of their personality. This is the way individuals have in the past developed a 'reputation' and a negative history, becomming further stigmatised.

Responding to challenging behaviour

The field of challenging behaviour is an extremely complex and technical one, with a range of specially trained people involved in seeking out solutions. Professional assessments are typically undertaken by psychologists, psychiatrists, community nurses and/or social workers. There are rarely quick fix answers. Support for an individual is often required from a whole team of carers and support workers, each with a different role to ensure the individual's needs are being met.

Formal descriptions of challenging behaviour

A Special Development Team at the University of Kent proposed a definition, which was used by the Kings Fund Centre in their research and educative work with challenging behaviour in the early 1990s. It culminated in their project, 'Facing the Challenge - an ordinary life for people with a learning difficulty and challenging behaviour'.

"Severe challenging behaviour refers to behaviour of such intensity, frequency or duration that the physical safety of the person or others is likely to be placed in jeopardy, or behaviour which is likely to seriously limit or delay access to the use of ordinary community facilities."

The Foundation for People with Learning Difficulties offers a more consumer-led definition:

"A small number of people with learning disabilities behave in ways which people without learning disabilities find difficult. For example, they may scream or hurt themselves. Some people behave like this because they are frustrated or because other people don't listen to what they have to say. The best way to help a person with a challenging behaviour is to find out from them what the problem is. Sometimes a person with challenging behaviour may need specialist help."

Challenging behaviour seen as a communication problem

The argument has been made that as all behaviour is learned at some point, this also applies to challenging behaviour. Starting from the assumption that all behaviour ('good' and 'problematic') comes with a message value, what is that behaviour trying to communicate?

We need to try and find out why some people express themselves in what appears to others to be a disturbed way, to discover which of their needs are not being met and find a constructive way to respond. In the past, there was often a tradition of blaming the person rather than looking for more wide-ranging causes. The problem is now seen as one of specific service delivery and the style of individual support a person is receiving.

An appreciation of some of the past negative experiences (and in some cases, clear abuse) a person has been subject to can help us identify why a person may now behave in a mal-adapted way. Sometimes bizarre but harmless behaviour leads to an individual avoiding a situation of stress because they don't have the skills to interact. Other times, attention-seeking behaviour evolves because a person has learned in the past it was the only way to get noticed and get what they needed. Aggression may manifest itself because an individual is frustrated and does not know how to communicate what is troubling them. A person may injure themselves because they are agitated or anxious. Boredom may produce stereotyped or ritualistic behaviour as a way of coping.

As these examples suggest, when we are considering challenging behaviour there is usually an underlying message from the individual. A constructive (rather than a punitive) change is generally required in a person's life or environment to begin to improve matters and to encourage more appropriate behaviour.

Assessing challenging behaviour

This will usually be undertaken by an experienced professional, who may be a consultant specially invited into a case to give advice and opinion. Whoever takes the lead will probably approach matters in a similar way by involving people who know the subject and asking them to make a contribution with information towards the overall assessment.

Behavioural assessment

This is generic term that should apply to a rounded or 'holistic' and functional assessment of a person. It will usually be based upon an accurate and detailed analysis of a person's current and past life experiences, their abilities and needs, plus their aspirations for their future.

Holistic assessment can be undertaken in many ways, sometimes using an assessment tool or form to help collect information. Each provider of a service or consultant may have their own preferred tool but they will essentially gather similar information.

Assessments may have alternative approaches e.g. those for people who have multiple disabilities are likely to employ different approaches and collect slightly different information than those for people who have a mild learning disability.

There are specific ways of working with people who have a learning disability, which are generally referred to as Person Centred Planning (see other areas of www.understandingindividualneeds.com). These approaches utilise a more general planning approach to support the everyday care of a person. An individual does not necessarily have to have challenging behaviour for a Person Centred Plan to be used. A consultant may, however, still use this process alongside others to help reach a challenging behaviour solution.

The content of a challenging behaviour assessment is likely to include information from the following areas:

• Previous life history
• What is currently happening in a person's life (e.g. current events, general quality of life)
• Their environment e.g. living environment, day service or daytime activities, routines
• General health e.g. current and past illness, medication, evidence of any pain, sight and hearing deficiencies
• Mental health e.g. any symptoms of depression, anxiety, mental illness
• Communication e.g. how a person communicates, any speech problems
• Noting a person's important relationships, friendships and family
• Leisure pursuits
• Comments regarding their abilities and skills
• A record of any identified needs
• The views of any advocate for the user
• Future wishes and aspirations

Direct observations

Additional information may be collected by other approaches involving:

• Observation of the person regarding a specific behaviour (e.g. how often something happens, how long it lasts and how intense it may be)
• Observing what was happening immediately before a specific behaviour (called the antecedents) and what happened directly after the event (referred to as the consequences)
• Directly observing the challenging behaviour and making notes. In some cases a video can make this task easier (but if this technique is used, appropriate reference to the correct procedures and ethics for directly filming a person should be undertaken). Shadowing someone through a number of hours in the day is another technique (doing this can sometimes quickly show how much real content there is in some people's lives!)
• Discussion - this could be direct if the person has appropriate language skills. Alternatively, informal and indirect disussion is feasible by sharing in activities with the person and engaging in a related dialogue in this way.

Some considerations when interpreting assessment information

People who are learning disabled also face an additional problem of social discrimination. In looking at how to combat these issues and how support services should be planned and delivered the work of John O'Brien has been particularly influential. In 1987 he described five essential priorities for people using services and the general themes of these were:

• People being able to make their own choices
• People being able to learn and develop skills and competencies
• Services should enhance the respect for users
• There should be participation in an everyday and ordinary life style
• Services and the individual should have a presence in the community

When considering service priorities for people who have challenging behaviour, the focus should be on any further impact on their lives (brought about by their behaviour) which has resulted in:

• The individual being separated away from the community, either in a special unit or by restriction of activities
• The challenging behaviour further restricting their choices (which may have been part of the problem in the first place) and a vicious circle developing
• The teaching of new skills and competencies, which could provide a way of meeting the person's needs, being blocked by challenging behaviour
• More stigma being placed upon the person who is seen in a negative way and develops a 'reputation' which ignores any positive qualities
• Participation in everyday activities becomes more and more restricted as the person's difficult behaviour escalates. Difficult behaviour can lead to isolation, which can lead to further problems.

Devising a support programme for challenging behaviour

After any assessment, the information and data gathered will be interpreted. With more complex problems, this usually includes trying to form a hypothesis as to the cause. As previously stated, challenging behaviour comes with a message, so any hypothesis is likely to embrace the following core concepts:

• What function does the behaviour (e.g. aggression) serve for the person in this context?
• What is the outcome the person achieves by their behaviour and why is it so important for them to get this?
• What other constructive alternatives are available to the individual to achieve these ends in this context?

Conclusions generally include the following:

• There is a problem in communicating feelings about needs
• There is a skill deficit in not being able to engage in a task or an experience properly
• There is a need for attention (for varying reasons)
• There is a wish to avoid a task (for varying reasons)
• A person is feeling unwell, in pain or has an unrecognised illness
• Personal wishes and choices are being overridden
• Boredom is demonstrated

Intervention and Management Plan

The strategy for managing challenging behaviours is recorded as a plan. This has a variety of names including Behavioural Plan, Individual Reactive Strategy and Behaviour Intervention Programme. These are forms of specific care plans, although these terms can also be given to the overall support programme for a person or user of a service.

Behavioural plans or strategies should clearly set out their objectives along with ways to achieve them. Everyone (carers and professionals alike) should be clear about their roles and responsibilities if they feature in helping an individual.

Risk Assessment

Some challenging behaviour may present a clear risk for the individual and, occasionally, for carers or staff. These risks have to be formally recognised for all parties. There should be risk assessments compiled to guide the intervention and help a person will receive. Risk levels and consequences should be agreed and boundaries set. Organisations have to consider corporate risk, as well as risk to the individual with the learning disability, through their duty of care. There are legal responsibilities for employers to keep their staff - as well as service users - safe and not exposed to excessive risk. Carers and service users must therefore work to a well formulated and officially recognised plan. Those participating in treatment programmes should not be left without direction or defined roles, as this could fuel the potential to react unilaterally, putting the programme and other people at risk.

Ethical dilemmas

The management of challenging behaviour can, on occasion, pose ethical dilemmas, e.g. the objective to increase a person's independence and maximise their choice, must be balanced against both the safety of the individual and others. The ethics of any plan should be sound and all dilemmas explored openly. If these are shared with the person's recognised advocate, it can help to promote trust and above all provide extra safeguards for the user.

Review of progress

It is essential to have a review of progress. The frequency of the review and method of recording progress should be part of the original planning but remain flexible to allow variations as required.