Chapter 71 – Padraig Ruane (D5SOP10)
Domain 5 Standard of Proficiency 10
Be able to identify, interpret, record and respond appropriately to patterns of behaviours displayed by service users in a variety of settings
|
KEY TERMS Patterns of behaviour Identify Interpret Record Respond appropriately |
Social care is … bringing it back to the person, remembering that they have the same rights as you and me. The person has dreams, desire and emotions like any human. In social care setting people are given many labels, e.g., a person with … intellectual disability, Down syndrome, autism, mental health problems. These diagnoses are often necessary to ensure the person gets the support they require, but we must not forget that above all they are people. Social care is protecting the humanity of the people we work with. |
Patterns of Behaviour
In the area of social care, in particular disability services, the term ‘behaviour’ is often associated with words such as ‘challenging’, ‘concerning’ and ‘responsive’. Social care degrees offered by third-level institutions tend to have a module on ‘challenging behaviour’. Multi-disciplinary teams often include a behavioural support specialist. Organisations such as Studio 3 and the Callan Institute provide training on managing challenging behaviour, multi-element behaviour support or positive behaviour supports. If you look at the policy section on the National Federation of Voluntary Bodies website you will come across a number of policies and guidance documents on the topic of behaviour, including supporting people with challenging behaviour, guidelines on management of behaviour that challenges. The area of challenging behaviour is heavily researched, but it is worth noting that absent from a lot of the research is the voice of the person and their contributions in term of what they believe works and does not work. As social care workers, supporting people who have behaviours that challenge is a major part of our role. This chapter will focus on the intellectual disability setting.
TASK 1
When you read the phrase ‘patterns of behaviour’, what comes to mind? Is it negative or positive?
Historical Context
The literature offers numerous definitions of what ‘challenging behaviour’ means. A widely used definition by Emerson et al. (2011) describes challenging behaviour as:
‘Culturally abnormal behaviour(s) of such an intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to seriously limit use of, or result in the person being denied access to, ordinary community facilities.’
In recent years, there has been a move away from using the term ‘challenging behaviour’. Jeffrey Chan and colleagues, in their article ‘Is it time to drop the term “challenging behaviour”?’, argue that the term ‘is associated with a crisis response approach to service delivery in which behaviours are assumed to be inherent in the people who exhibit them.’ The most common alternatives are: behaviours of concern; responsive behaviours; behaviours that challenge. It is important to note that despite the move away from the term ‘challenging behaviour’, Emerson’s definition is still widely accepted and can also be used for the alternative terms. The purpose of moving away from the term ‘challenging behaviour’ is to show that it is not inherent in the person or a diagnosis.
Challenging behaviour is not a diagnosisIt is important to note that ‘challenging behaviour’ is not a disorder that a person can be diagnosed with. When working in the area of social care you may hear phrases such as ‘her challenging behaviour’ or someone being described as ‘having challenging behaviour’. This use of the pronouns and verbs implies that the issue is in the person. It is important torecognise that the behaviour is rather the result of an interaction between the person and their environment.Research has shown that there is higher incidence of ‘behaviours that challenge’ in people who communicate differently, have diagnosis of severe to profound intellectual disability, autism, mental health issues, visual impairment and hearing difficulties. This is often as a result of the setting or environment not being adapted to meet the person needs.
Behaviour as Communication
Behaviours that challenge should be considered a means of communication. Read the following example:
Case Study 1
David is young man with Down syndrome and he communicates differently. As part of his weekly schedule he goes for a walk in the local park on Tuesdays. Staff have noticed recently that David is reluctant to go on the walks. He has refused to put on his walking shoes. On occasion he become upset and has thrown his shoes, nearly hitting staff and fellow residents.
Take a moment to think about what David could be communicating with his behaviour.
Is he in pain? He could be communicating pain or discomfort. Are the walking shoes hurting him? Do they fit him properly?
Is the activity the problem? Is he communicating that he doesn’t want to go on the walk? Perhaps he doesn’t enjoy it? Perhaps the weather is getting colder?
Are the people he is going with a problem? Is he communicating that he doesn’t want to go with the staff or residents? Does he refuse to put on his shoes every week or only with certain staff?
Is he communicating his frustration at a lack of choice? Does David want to go on the walk? Often exercise is recommended for people by their GP and a schedule is developed without the person being involved. Is there something else he would rather do?
Is David aware of the schedule? Does he know that he is due to go for a walk? Oftentimes someone’s weekly schedule is placed in the personal file. Would David benefit from having a visual timetable? Do certain staff have a better way of communicating with David in advance?
As you can see, a simple behaviour such as a person refusing to put on his shoes can be communicating a number of things. It takes keen observation skills and high level of awareness from the social care worker to identify and interpret the behaviours. This brings me on to the fact that behaviour that challenges can be subjective.
It is important to note that when a person communicates differently it is often the case that decisions are made on their behalf without proper involvement of the person. There can be a belief that a person would not understand and cannot make decisions. In line with the principles of the Assisted Decision-Making Act 2015, there should be the presumption of capacity. Information should be provided to the person in an accessible way and they should be supported to communicate their will and preference using any communication method required.
Staff Interpretation
Take the case study example. Imagine that there are two social care workers supporting David that day. They both witness the incident. Each social care worker may come away with different interpretations. Social care worker A may see the behaviour as a refusal to engage in the walk and that David has responded inappropriately. Worker A may suggest developing a support plan to help David engage in the activity. Social care worker B may feel that David’s refusal to put on his shoes is a method of communication, and they may suggest developing a support plan to explore what is being communicated.
If the shoes were causing David pain, refusing to put them on would be an appropriate response and would show a level of insight. This behaviour is actually quite adaptive and functional from David’s perspective. The reason the behaviour is challenging is because the service is not adapting to his needs. The person may require communication supports, e.g., Lámh, PECS or communication devices. The service may need to review the staff roster, schedules, etc.
When we talk about behaviours that challenge it is important to ask, ‘Who does the behaviour challenge?’ Take the following example:
Case Study 2
Carol has moderate disability with mobility issues. She lives at home with her parents. Carol frequently wakes up during the night and will sometimes go for a walk around the house. Her mother is concerned that she is at risk of falling down the stairs and injuring herself. Carol waking up early in the morning is challenging for her parents as they have to get up with her. There is no doubt that the consequences of this behaviour are challenging to the parents, but with the correct supports the behaviour would not be deemed challenging. If Carol was living in a bungalow with night staff, her waking up during the night would not be an issue.
Context
The context and setting where a behaviour occurs can influence whether or not it is deemed challenging (Emerson and Einfeld 2011).
TASK 2
Think about the following situations. Think about what behaviours are acceptable and unacceptable in each.
- Visiting a library
- Watching football match
- Attending a music concert
- Attending a religious service
Notice that behaviour that is acceptable in one setting, such as shouting and cheering at a football match, is unacceptable in another, such as visiting a library. Think about the music concert: depending on the genre of music and venue there may be major differences in what is acceptable. The crowd behaviour at an open-air rock concert may be very different from a seated audience at an orchestral recital. The behaviour appropriate at a religion service will depend on the particular religion and culture.
Having an understanding of patterns of behaviour is important in the area of social care. The role of the social care worker is to identify, interpret, record and respond appropriately to the person’s behaviours. That is what we will discuss next.
Identify
Identifying the Behaviour
The first thing you must do is identify the specific behaviour or behaviours. What is the person doing? Rather than simply saying the person is displaying ‘behaviours that challenge’, identify the actions. Are they shouting, scratching their arm, pushing a fellow resident?
As social care workers we must be aware that people can become labelled as displaying ‘behaviours that challenge’. This can result in an attitude among staff of ‘That’s just how he behaves’, or ‘That’s just what she does.’ This can lead to staff becoming immune to behaviour, for example ‘Julie always shouts, it doesn’t mean anything’, or interpreting all behaviours as challenging.
It is important to take time to identify the behaviour and not jump straight into interpreting every behaviour as ‘behaviours that challenge’.
Identifying the Setting Event
A setting event is anything that increases the person’s anxiety or decreases their ability to tolerate a situation. The setting event can be something that happened in the past or in the build-up to the behaviour, for example not getting enough sleep the night before, an incident in day service, the person feeling sick. A setting event can be a one-off event such as a cancelled visit with family or a build-up of events over time that can lead to an increase in anxiety. Setting events happen to everybody, whether or not they have an intellectual disability. The social care worker plays an important role in identifying the setting events. Through building a relationship with the person, the social care worker will develop a deep understanding of them. The social care worker will be able to identify setting events that the person may not be aware of. This is particularly important where a person communicates differently.
Identifying the Trigger
A trigger is an event that occurred immediately before the behaviour that ‘caused’ it. Being aware of potential triggers can be the first step in developing a support plan to reduce behaviour. Some common examples of triggers are:
- Being asked to do something or being told not to do something
- A noisy or busy environment
- A particular individual or activity
- Being bored.
The knowledge and insight the social care worker has of the person will allow them to identify triggers.
TASK 3
Imagine you have just started a new job in a residential service for people with intellectual disability. During your induction you are told that one of the residents, James, ‘has challenging behaviour’ without any details about what the behaviour is, what the setting event or triggers are. Think about how ill- prepared you would be to support James. In situations like this it is important to ask for further information: What are the specific behaviours, setting eventand triggers?
Interpret
When behaviours that challenge happen it may seem like there is no obvious reason, but there always is a reason and the challenge for services is to work out what the purpose of the behaviour is. The Challenging Behaviour Foundation has developed the following table, which outlines four areas to consider.
|
Social Attention: We have all heard the saying, ‘It’s just attention-seeking behaviour.’ It isn’t bad to want attention from others. However, for a variety of reasons (e.g., limited communication skills, boredom, or an inability to occupy themselves), some people may learn that behaving in a particular way is a reliable way of attracting others’ attention, even if it is negative attention. |
|
Tangibles: Here it is the desire for certain things (e.g., food, drink, objects or activities) which is providing the motivation for the behaviour. Again, it isn’t bad to want these things. If you are hungry, it makes sense to try and get something to eat. If you see something in the shop that you like, it makes sense to try and get someone to buy it for you. However, it becomes a problem when the person learns to act inappropriately to get these things. |
|
Escape: While some people like attention, others would prefer to be left alone. Rather than behave in a particular way to get people’s attention, some people will behave in a way that helps them to avoid/escape situations or activities that they don’t like, or don’t find that rewarding. |
|
Sensory: Sometimes behaviour is internally rewarding, or self-reinforcing, i.e., what is happening around the person (externally) is not as important as what is happening inside the person |
Source: Challenging Behaviour Foundation Information Sheet (www.challengingbehaviour.org.uk).
Record
Recording should be done in line with policy and best practice guidelines. (See Domain 3 Standard of Proficiency 2 for further information.) When recording an incident it is important to remember the following: be factual; describe specific behaviour (e.g., ‘Colm bit his arm’ rather than ‘Colm engaged in challenging behaviour’); and note any setting events and triggers. It may take a long time to understand the reason behind a behaviour. Having accurate reports is vital in helping the service get a full picture of the behaviour. As a social care worker you may feel that it is a reflection of your skill as a professional if a person engages in behaviours that challenge when you are working with them. This may make you reluctant to report incidents. But it is important that you report all incidents; there are often multiple reasons for a person’s behaviour, not solely their interaction with staff. If there is an area that you need to improve on, your manager and service should provide you with supervision, coaching and training to develop skills in this area.
Respond
A common method to support people with behaviours that challenge is by using positive behaviour support. It is an evidence-based approach with the primary aim of increasing the person’s quality of life and the secondary benefit of decreasing the regularity and severity of their behaviours that challenge.
What is Positive Behaviour Support?
The key components of positive behaviour support are:
|
Person-centred |
Inclusion of relevant stakeholders |
Assessment-based |
|
Support plans |
Reduction in restrictive practice |
Skills building |
|
Staff development
|
Environment change |
Systems change |
What does a Behaviour Support Plan Look Like?
Behaviour support plans include the following three areas:
- Primary prevention: This means putting in place supports to meet the person’s unmet needs. Examples of such supports are making changes to the person’s environment, improving communication, enhancing active engagement in meaningful activities.
- Responding to early signs of behaviour: This part of the behaviour support plan aims to find out what the person is communicating through their behaviour and provides a prompt for staff to respond effectively to the early behaviour before it escalates.
- Reactive strategies: How to effectively respond to the behaviour when it happens. The plan aims to ensure:
- the safety of the person and others around them
- that the least restrictive practices are used
- that the person develops new skills and re-engages in positive behaviour and interactions as quickly as possible.
Social Care Worker Input into Multi-disciplinary Teams
It is common for behaviour support plans to be developed by a multi-disciplinary team (MDT). The social care worker has an important role here as they are the professional who knows the person best and witnesses first-hand the person’s behaviours. The quality of the behavioural support plans developed by the MDT relies on the information they receive from social care workers working directly with person.
The success of the positive behaviour support approach is reliant on the skills and commitment of the social care workers implementing the plan. When it comes to reviewing the plan the social care worker plays an important role in providing feedback to the MDT team. The social care worker plans an important role in ensuring that the person is included in developing the plans as much as possible.
Tips for Practice Educators
- Move away from the term ‘challenging behaviours’ to ‘behaviours that challenge’, ‘behaviours of concern’, ‘responsive behaviours’.
- The importance of behaviour as communication.
- Challenging behaviour is not a diagnosis.
- Importance of accurate recording. Having accurate reports is vital in helping the service get a full picture of the behaviour and developing supports.
- The important role social care workers play in MDTs as they work directly with the person, implement the plan and can give feedback on its effectiveness.
- There should be a focus on what students may see or experience. There should be an acknowledgement that they may be fearful initially, but seeing the behaviour as communication will help, and support will be provided.
- Supervision and promoting reflective practice is important.
References
Chan, Jeffrey, French, Phillip and Webber, Lynne (2011) ‘Positive behavioural support and the UNCRPD’, International Journal of Positive Behavioural Support 1.
Chan, Jeffrey et al. (2012) ‘Is it time to drop the term “challenging behaviour”?’, Learning Disability Practice 15(5), June 2012: 36ff.
Challenging Behaviour Foundation (2020) Policy and Best Practice. [Online] Available at: https://www.challengingbehaviour.org.uk/information/policy-and-best-practice.html [Accessed 26 September 2020].
Emerson, E. and Einfeld, S. (2011) Challenging Behaviour (3rd edn). Cambridge: Cambridge University Press.
Government of Ireland (2015) Assisted Decision-Making (Capacity) Act 2015. Available at: <http://www.irishstatutebook.ie/eli/2015/act/64/enacted/en/html>.
NICE (National Institute for Health and Care Excellence) (2015) Challenging Behaviour and Learning Disabilities: Prevention and Interventions for People with Learning Disabilities Whose Behaviour Challenges. London: NICE.
