Challenging behaviour is a term used to refer to problematic or testing behaviours that children, young people and adults can present. Aggression (hitting out, biting, pinching), destruction of property (breaking things), self-injury (e.g. biting, picking, head banging) and many other behaviours fall under the heading of ‘challenging behaviour’. These behaviours have the potential to cause significant harm to the person and others around them and can impact on their life including family relationships, schooling, leisure pursuits, health and overall care.
Although anyone can present with challenging behaviour the term itself has become associated with people with learning disabilities as the severity of learning disability and associated impairments such as poor mobility, visual impairments, autism, sensory impairment and epilepsy, difficulties with communicating and some conditions that cause learning disabilities heighten the likelihood for challenging behaviour. This is sometimes referred to as stereotypical behaviour or behaviour phenotype. For example Fragile X is associated with hand/finger biting. Rett Syndrome is associated with hand wringing. Lesh- Nyhan is associated with hand/lip biting. Prader-Willi is associated with skin scratching/picking, pica (eating inedible substances).
Why does challenging behaviour occur?
Understanding the cause of challenging behaviour is far from simple. Typically parents often find their children start to have tantrums as they develop independence and want to do things that parents have to limit. However, most develop communication and social skills that help them get their needs met. This process is often delayed in children with learning disabilities and associated difficulties. Children and adults with severe disabilities are often unable to speak or have limited communication skills. Being unable to make simple, often reasonable requests (for a drink or to stop an activity) can be communicated through ‘challenging behaviour’. Imagine a child cannot crawl or walk, feels bored, is in pain or uncomfortable and wants to interact with those around them to play, eat, be repositioned or have hygiene needs met, but lacks communication skills to request this. Crying, shouting, harming oneself or lashing out may be how he starts the ‘conversation’. As those around him respond to this the behaviour and meet the needs, the ‘challenging behaviour’ is accidently reinforced. Let’s say a child with learning disabilities is scared by change or new people, he may engage in ‘challenging’ behaviours to communicate this and avoid difficult situations. When hitting out the child is removed from the situation and learns hitting out is an effective way to leave uncomfortable situations. This can be really confusing for parents and families. For example, whilst most children love parties or spending time with others some children prefer to be alone and may use ‘challenging behaviour’ to communicate this; pushing people away or running away. Some children may learn to self-stimulate when they are bored for example rocking, spinning, jumping, eye-poking, biting or picking their skin. This can be very distressing for loved ones and carers and may disrupt learning and ordinary family life. However, for loved one challenging behaviour can feel deliberate, premeditated and designed so the individual can ‘get their own way’ or ‘get attention’. It is important to keep in mind the persons ‘intent’ and ask ourselves what function the behaviour is serving.
Whilst it is generally accepted that challenging behaviour is more common in people with learning disabilities it is not inevitable and we must remember each person is unique. All human behaviour has meaning and can be changed. Understanding the meaning of challenging behaviours(s) is the key to understanding how to best to respond.
Establishing the cause of challenging behaviour
Common reasons for challenging behaviour include:
- Seeking or avoiding physical or sensory needs
Does the individual need food, drink or use the toilet? Does the individual have an unmet sensory need for noise, movement, visual stimulation? Or is the individual in pain, unwell or overwhelmed with sensory sensitives and wanting to avoid unwanted noise, touch or movement?
- Seeking or avoiding social or leisure needs
Is the individual seeking physical contact, interaction, attention, a break or play? Or is the individual avoiding specific activities or close contact with others?
- Seeking or avoiding learning or experiences
Is the individual seeking a specific toy or object, activity, wanting to engage in a specific interest, needing a break or help to do a task? Or is the individual scared and avoiding specific toys, objects, experiences, people, environments or changes to his/her routine?
- Thoughts and feelings
Is the individual confused or unable to understand events, others intentions, relationships? Is the individual rigid and unable to accept change?
Functional Analysis of challenging behaviour and developing individual behaviour support plan
Assessment of challenging behaviour is often called a ‘functional assessment’ or ‘functional analysis’. Either way thorough assessment of what happens before, during and after episodes of challenging behaviour guides the professional undertaking the assessment in the development of theories that help everyone understand the function(s) of specific behaviours. Ideas about the function of specific challenging behaviours are used as the basis for individualised behaviour support plans to stop, reduce or encourage alternative behaviours. It is important to note that the causes of challenging behaviours can be very complex and unclear, even after functional analysis, but support plans built on uncertain theories can be very helpful.
Individual behaviours support plans
Individual behaviour support plans aim to draw all the information together and develop a personalised plan to promote safety and identify what alternative skills may help an individual get their needs met in a safe way. It may focus on:
- Teaching the individual to communicate their needs through signs or pictures.
- Teaching the individual some independence skills such as dressing, personal care, road safety.
- Teaching the individual how to ask for help, a break or to wait for a desired object.
The functional analysis assessment process
- An initial assessment taking approximately two hours in a face to face interview will explore the presenting problems, previous interventions and management strategies tried , family composition and health, the individuals personal development, diagnosis, mental state, communication skills, and recent family stressors. The outcome for this session will be a clear definition of the challenging behaviour in question and the settings in which it occurs and agreement if any other assessment is indicated such as health or communication.
- The next stage is the functional assessment of specific behaviours. The person undertaking the functional analysis will arrange to observe the child/young person in the home, school and respite facilities.
- Parents/carers from each of the setting will be asked to complete a range of rating scales and questionnaires and keep detailed recordings of the behaviour in question for a minimum of two weeks.
- Information generated will be processed and reviewed before the follow up session when parents/carers will meet with the person undertaking the functional analysis to review the findings and develop theories about the function (s) of the behaviours.
- A behaviour support plan will be developed together with key people involved including family, care and school staff to outline how to prevent and / or manage behaviour. This will include keeping behaviour monitoring records to be reviewed at follow up appointments.
- The behaviour support plan will be reviewed after two, four and six weeks and adapted as necessary.