Finding Reasons for Challenging Behaviour PDF

INFORMATION SHEET Finding the Reasons for Challenging Behaviour: Part 2 All behaviour happens for a reason All our information sheets are available to and understanding why someone download free of charge because we believe might display behaviour...

INFORMATION SHEET Finding the Reasons for Challenging Behaviour: Part 2 All behaviour happens for a reason All our information sheets are available to and understanding why someone download free of charge because we believe might display behaviour that that money should not be a barrier to getting challenges is vital. This information the information you need when you need it. sheet aims to further your understanding of challenging Please see the end of this information sheet behaviour and help you to identify for details of how to support us. times and situations when the We want to make sure our resources are behaviour may be more likely to helpful. Please spend a few minutes giving occur. us some feedback: www.surveymonkey.co.uk/r/cbfresources. We look at what may lead to this behaviour, as well as the different stages of behaviour, and explain how a ‘functional assessment’ can increase our understanding of challenging behaviour. Finding the Reasons for Challenging Behaviour is the second information sheet in this series. It is recommended that it is read alongside ‘‘Understanding Challenging Behaviour: Part 1’’ and “Positive Behaviour Support Planning: Part 3’’ Why does it happen? Very young children often display challenging behaviour at around two years old. They know what they want but they don’t have the language or social skills to get it. They can’t say what they want and so continue the ‘terrible twos’ until the child develops the skills needed to communicate in a more socially acceptable way. Children or adults with a severe learning disability are also typically either unable to talk or have very limited verbal communication skills. As they cannot express their needs verbally, they must use other ways to get their needs and wants understood and met, and so challenging behaviour may continue. The needs that the person wants to have met are reasonable (e.g. wanting a drink or wanting to stop an activity that they don’t like). It is simply the way that they are communicating the need that is problematic. People with learning disabilities sometimes have very little choice or control over their lives. Anyone who is not given choices and is unable to control what happens in their day to day life is at risk of developing challenging behaviour. It can be a very effective way of influencing what happens to you! It may be tempting to think that people “know exactly what they’re doing”, but remember, many of our own immediate reactions to situations are fairly automatic, particularly when we are feeling scared or angry. Do you intend to raise your voice when you are stressed, or does it just happen? Sometimes a person’s behaviour is an emotional response over which they have little control. © The Challenging Behaviour Foundation. Registered charity no. 1060714. www.challengingbehaviour.org.uk Registered office: The Old Courthouse, New Road Avenue, Chatham, ME4 6BE. Tel. 01634 838739  ~2~ Challenging behaviour in people with severe learning disabilities is not deliberate or planned. Rather, in situations of need, people with severe learning disabilities may simply behave automatically in ways which have been successful in the past. People will learn to use what works. The first step in understanding challenging behaviour is to try and find out why the behaviour is happening. Common reasons include: Health It is important to first rule out an underlying medical problem. If the person is experiencing pain or discomfort and is unable to tell carers this, challenging behaviour may occur. Often health conditions are missed due to ‘diagnostic overshadowing’ when professionals attribute the behaviour to the person’s learning disability. If someone’s behaviour suddenly gets worse, one of the first things to check with a GP or nurse is their health. Common conditions such as ear infections, tooth-ache, constipation, urinary tract infections or epilepsy, may all cause challenging behaviour. It is essential to get the right treatment for these health conditions. Similarly, untreated mental health conditions in people with severe learning disabilities can cause or increase challenging behaviour. Like physical problems, mental health conditions should be explored, and people should get the treatment that they need. Adults and young people over the age of 14 with severe learning disabilities are entitled to a free annual health check. This is usually carried out by the person’s GP and helps the person to stay well and identify any health needs early and so the right treatment can be given. Change It is also important to consider if there have been any big changes in the person’s life that could be causing the person to display challenging behaviour. Has a brother or sister left home? Has there been a death in the family, divorce, a house or school move, or a favourite carer leaving? These are important issues and the person may need support to understand and come to terms with these. What is the purpose (or Function) of the challenging behaviour? When challenging behaviour happens it may seem as though there is no obvious reason. Statements like, “That’s just what John does” or “It just came out of the blue”, are common. However, there will always be a reason why the behaviour has happened. Although confusingly, the reason it is happening now won’t necessarily be the reason it started. The challenge for families and paid carers is to work out the purpose of the behaviour for the person and how to prevent it from happening again. Although there are many reasons why a person may display challenging behaviour, there are four common purposes: 1. 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 © The Challenging Behaviour Foundation. Registered charity no. 1060714. www.challengingbehaviour.org.uk Registered office: The Old Courthouse, New Road Avenue, Chatham, ME4 6BE. Tel. 01634 838739  ~3~ themselves) some people may learn that behaving in a particular way is a reliable way of attracting any kind of attention from others. For example: Sarah loves 1:1 Sarah wets The teacher or Sarah gets 1:1 The function adult interaction, herself assistant takes time with an adult. of Sarah’s but at school Sarah Sarah out of She learns that behaviour is must share the the classroom when she wants that it gets her teacher or to help her attention from an ATTENTION assistant’s time clean up and adult at school with the rest of the change into dry that she wets class. Sarah is clothes herself then she sitting unattended. gets attention 2. Tangibles: Sometimes the desire for certain things (e.g., food, drink, objects or activities) provides the motivation for the behaviour. Again, it isn’t bad to want these things. If you are hungry, it makes sense to try to get something to eat. If you see something in the shop that you like, it makes sense to try to buy it. However, it becomes a problem when the person learns to act inappropriately to get these things. For example: Tom is thirsty He finds a cup and Tom gets given Tom has The function of throws it at a drink learned that Tom’s someone when he behaviour is wants a drink that it gets him he throws a something cup and he TANGIBLE gets a drink (i.e., a particular item that he wants) 3. Escape: Whilst many people like attention, some would prefer to be left alone at times. 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. For example: Holly doesn’t Holly hits The teacher takes Holly learns that when The function enjoy/like the person Holly to sit out in the she wants to be taken of Holly’s group in the group quiet corridor out of a group activity, behaviour is activities sitting she hits someone and that it helps nearest to gets removed from the her her class ESCAPE 4. 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. For example: Farhan has been Farhan Farhan likes the Farhan learns that The function of on his own in the rocks feeling he gets when he has Farhan’s sitting room for 20 back and from this, he can nothing to do he behaviour is minutes, he is forth and do this for a long can stimulate SENSORY unable to occupy hums time himself by rocking himself loudly and humming © The Challenging Behaviour Foundation. Registered charity no. 1060714. www.challengingbehaviour.org.uk Registered office: The Old Courthouse, New Road Avenue, Chatham, ME4 6BE. Tel. 01634 838739  ~4~ The behaviour displayed may appear pointless, annoying or distressing to the observer. However, for the person themselves, the behaviour may serve the function of helping them cope with unpleasant negative feelings such as boredom or anxiety. Although a challenging behaviour may appear negative to us, the behaviour may serve as a positive coping strategy for the individual: if you can’t cope with someone sitting too close, biting them will make them move away! Whatever the function of the behaviour is, there will be certain times and specific situations when you could predict that a person may be more likely to display challenging behaviour. Understanding “Setting events” and “triggers” to behaviour for the person you care for can help you to avoid certain situations or put things in place which could help to prevent an incident of challenging behaviour. Setting events A setting event is anything that increases a person’s level of anxiety or makes a person more sensitive to and less tolerant of people, environments and situations. Setting events can also be called ‘slow triggers’. A setting event can be something that happened in the past (e.g., being near someone who was upset or angry; or not getting enough sleep the night before), or it can be about what is happening now (e.g., feeling ill, hungry or thirsty; or going into a crowded/noisy room). Setting events build up over time and increase the person’s level of anxiety or sensitivity. The more setting events there are, or the more anxiety they cause, the more likely someone is to display challenging behaviour in response to a ‘trigger’. For example, asking a young person to put their shoes on might be fine on a good day, but on a day when several setting events have occurred, e.g., they’re feeling unwell and have had little sleep, the same request might trigger a response like throwing the shoes. Setting events happen to everybody whether we have a learning disability or not. The difference is that we usually have a clearer understanding of what is happening and can do something about it. For example, if we are tired, have a head ache and have to get on a busy train, we might take a paracetamol, try to nap and block the noise out with headphones. We also understand that it won’t last forever and so we can just cope until it’s over. Identifying triggers A trigger is the event that happens immediately before the challenging behaviour to ‘cause’ it. This is also known as an ‘antecedent’. To use an everyday phrase, it is the straw that broke the camel’s back. Being aware of the potential triggers for challenging behaviour can be the first step in reducing the behaviour. Knowing what the triggers are can help you to avoid them. If you can’t avoid them, it can help you to predict specific times that challenging behaviour may be more likely to happen, so you can help the person to cope better. © The Challenging Behaviour Foundation. Registered charity no. 1060714. www.challengingbehaviour.org.uk Registered office: The Old Courthouse, New Road Avenue, Chatham, ME4 6BE. Tel. 01634 838739  ~5~ Some common examples of triggers are: Being asked to do something - or told to stop doing something Being told you can’t have or do something you want A particular individual or activity Entering a noisy, hot, or crowded place Being bored, or not being spoken to or involved Not understanding what you are being asked to do Knowing the triggers for the person you care for can help you to put things in place to reduce their anxiety. For example, if someone hates crowded places you could identify quieter times to go shopping and teach the person a way to communicate that they are anxious and want to leave. Providing the person with more control over their environment and a way to communicate could help them to manage their anxiety and prevent their behaviour escalating. Different stages of behaviour: Challenging behaviour can happen very quickly or with signals that are hard to spot but is unlikely to come ‘out of the blue’. Behaviour develops in stages and the ‘arousal curve’ diagram below shows these: Red (Reactive phase) Incident Amber (Active phase) Blue Anxious, aroused, (Post reactive agitated or phase) distressed Calming down but still need to be careful Green (Proactive phase) Happy, calm and contented Figure 1: Arousal curve showing different stages of behaviour The Green ‘Proactive’ phase is where the person is feeling mostly calm and relaxed and can engage positively with you in a meaningful way. The aim is to try and support the person to stay in this phase as much as possible. It is important to think about what it is that is helping the person to feel calm and relaxed and to plan this into their day. The reen Calm & relaxed © The Challenging Behaviour Foundation. Registered charity no. 1060714. www.challengingbehaviour.org.uk Registered office: The Old Courthouse, New Road Avenue, Chatham, ME4 6BE. Tel. 01634 838739  ~6~ green phase is when the person is most able to learn useful skills to help them get what they want and need. The Amber ‘Active’ phase is where the person may be starting to feel anxious or distressed and there is a chance that they may escalate their behaviour. Here we need to take swift action to support the person to return to the Green Proactive phase as quickly as possible, to prevent an escalation to the crisis phase. The amber arrow on the Arousal Curve diagram points in both directions because the person’s arousal (or distress) can go up or down. In the Amber ‘active’ phase we can see ‘early warning signs’ that the person is expressing that they are anxious; wanting something they are unable to ask for verbally; not liking something; feeling bored, etc. These early warning signs provide the opportunity to intervene before the behaviour escalates to a full-blown incident of challenging behaviour and taking the time to spot them is essential. The Red ‘Reactive’ phase is where challenging behaviour actually occurs, and we need to do something quickly to achieve safe and rapid control over the situation to prevent unnecessary distress and injury. The final Blue ‘Post Reactive’ phase is where the incident is over, and the person is starting to recover and become calm and relaxed again. We still need to be careful here as there is a risk of behaviour escalating to red again – the blue arrow on the Arousal Curve also points in both directions. Identifying the different stages of behaviour can help you to make sure the person has what they need on a day to day basis. Functional Assessment An assessment of challenging behaviour is usually called a ‘functional assessment’ and aims to provide some answers about the reasons behind an individual’s behaviour. By conducting a functional assessment, you are learning about people before you intervene in their lives. Rather than basing support strategies simply on ‘hunches’, ‘trial and error’, or ‘what seemed to work for someone else’. A functional assessment will guide the development of a more individualised behaviour support plan. A functional assessment is usually carried out by a Psychologist or other behaviour specialist in collaboration with parents/ family carers or primary carers. How you access this service will vary in different parts of the UK, but your GP or Social Worker will advise you. As a family carer, you are likely to be asked questions about the challenging behaviour of your family member. This may be in a face-to-face interview, by questionnaire or you may be asked to fill in rating scales. You may also be asked to keep a recording chart (see next section). In addition to this, the person doing the functional assessment may also observe the behaviour where it usually happens e.g., in the family home, the school, or the supermarket. If this is the case invite them on a typical day, don’t increase support staff or reduce demands especially for the day of the observation. It is actually helpful if © The Challenging Behaviour Foundation. Registered charity no. 1060714. www.challengingbehaviour.org.uk Registered office: The Old Courthouse, New Road Avenue, Chatham, ME4 6BE. Tel. 01634 838739  ~7~ the professional sees the behaviour for themselves. The professional doing the assessment will analyse all the information collected to conclude the most likely function(s) of the challenging behaviour. Recording Behaviour Keeping a record of challenging behaviour can help identify its function. It is important to record: 1. A definition of the challenging behaviour in question: Before conducting a functional assessment, it is essential to have a clear definition of the behaviour of concern. This is a description of what the behaviour looks like, which may include specific examples of the behaviour, as well as how often it happens. For example: Rather than saying “John has tantrums”, which does not provide a clear description of the actual behaviour, it is better to agree a specific description such as, “John pulls another person’s hair with one or two hands”. As a functional assessment may consider information provided by more than one person, it is important that everyone has exactly the same definition of behaviour in mind. 2. Early warning signs (from the Amber Active phase): In addition to defining the challenging behaviour itself, it can be helpful to define the ‘early warning signs’. These simply refer to any physical signs or behaviour that tend to happen before the challenging behaviour occurs. For example, someone becoming red in the face and starting to pace up and down quickly may be a typical sign that they are feeling anxious, which could lead to aggressive behaviour. 3. An assessment of the trigger/antecedents (i.e. what happens before): Certain things often appear to trigger challenging behaviour. They can be more immediate triggers (e.g., being told “no”, or being refused something), or ‘setting events’, which refer to situations where the person is more likely to resort to challenging behaviour (e.g., crowded/noisy environments, the time of day, unpredictable routines, pain, or illness). 4. An assessment of the consequence (i.e. what happens after): What is the person getting, or not getting from the behaviour that motivates them to repeat it? Many consequences are externally motivating e.g., the consequence of banging your head may be that you gain more or less attention from people; get a desired object, food or drink; or escape from an activity or task. Consequences may also be internally motivating e.g., the consequence of banging your head when you are feeling bored, may be that you feel more stimulated. There are lots of different methods of recording information about an individual’s behaviour and a commonly used tool is known as the ABC chart where A stands for ‘Antecedent’, B for ‘Behaviour’ and C for ‘Consequence’. © The Challenging Behaviour Foundation. Registered charity no. 1060714. www.challengingbehaviour.org.uk Registered office: The Old Courthouse, New Road Avenue, Chatham, ME4 6BE. Tel. 01634 838739  ~8~ The aim of ABC charts is to identify links between the behaviour and its antecedent and consequences, to aid understanding of the function that the particular behaviour serves for an individual. Appendix 1 provides a blank chart which may be printed and photocopied Appendix 2 provides an example of an ABC chart which includes suggestions about the type of information that may be useful to include under each heading Appendix 3 Provides an example of a completed ABC chart, showing good and bad examples of recorded information Although the process of using ABC charts is relatively straightforward, it can be complicated by the fact that the recording is often done by more than one person (e.g., parents, short break carers and teachers). In addition, a person’s behaviour may serve more than one function, be used for different purposes in different locations and be responded to in different ways by different people. Again, this makes it really important for everyone to decide on a good clear definition of the behaviour before people start recording. Outcomes of Functional Assessment The aim of a functional assessment is to understand what the purpose of the behaviour is, so that we can help the person to use other ways to get their needs met. Once you have a good idea about the function of the behaviour, you can start to think about how to respond to that behaviour. The results of the functional assessment should inform any strategies that are introduced, with the aim of stopping, reducing or encouraging alternatives to challenging behaviour. Ultimately, the aim is to support the person to learn ways to get their needs met, that are as good as, if not better than, challenging behaviour. However, it is important to recognise that challenging behaviour can occur for very complex reasons and for some people those reasons remain unclear, even after a functional assessment has been carried out. Nevertheless, even behaviour support plans based on tentative theories can be useful in the long-term because everyone is working from the same plan and providing consistent support. Positive Behaviour Support Plans The next step is to use the information gained from the functional assessment to plan how to reduce challenging behaviour or lessen the impact on the person and those around them. A Positive Behaviour Support Plan draws together all the information from the assessment to create an individualised plan to help keep everyone safe. It can also identify where the person would benefit from being taught additional communication or other skills. For example: © The Challenging Behaviour Foundation. Registered charity no. 1060714. www.challengingbehaviour.org.uk Registered office: The Old Courthouse, New Road Avenue, Chatham, ME4 6BE. Tel. 01634 838739  ~9~ Teaching them another form of communication such as signs or picture cards to indicate they have finished an activity or to ask for a drink Teaching someone who has difficulty waiting strategies to cope better with waiting Helping someone to develop skills that will enable them to be more involved in day to day things, such as domestic chores, getting dressed and personal care A good behaviour support plan can ensure that everyone involved with a person’s care and support has a shared plan, based on an agreed understanding of the causes of the person’s challenging behaviour. This provides a consistent approach, to helping people with severe learning disabilities feel secure and happy and to increase their independence skills. With thanks to Mark Addison, Consultant Clinical Psychologist, Rapid Intervention Team, Somerset Partnership NHS and Social Care Trust. Further information about Positive Behaviour Support Plans can be found in the Challenging Behaviour Foundation’s information sheet “Positive Behaviour Support Planning”. Last updated January 2019 The Challenging Behaviour Foundation We are the charity for people with severe learning disabilities who display challenging behaviour. We make a difference to the lives of children and adults across the UK by: Providing information about challenging behaviour Organising peer support for family carers and professionals Giving information and support by phone or email Running workshops which reduce challenging behaviour To access our information and support, call 01634 838739, email [email protected], or visit our website: www.challengingbehaviour.org.uk If you have found this information useful, please consider making a donation. You can show your support at www.challengingbehaviour.org.uk/support-us. Make a £5 donation by texting CBFDN05 to 70085 Or email us to get involved at [email protected] © The Challenging Behaviour Foundation. Registered charity no. 1060714. www.challengingbehaviour.org.uk Registered office: The Old Courthouse, New Road Avenue, Chatham, ME4 6BE. Tel. 01634 838739 Appendix 1 ~ 10 ~ TIME DATE & NAME: Location, people, ANTECEDENT activity Describe what you saw BEHAVIOUR ABC RECORD CHART the person react What did the carer do/how did CONSEQUENCE POSSIBLE REASON/ PURPOSE © The Challenging Behaviour Foundation. Registered charity no. 1060714. www.challengingbehaviour.org.uk Registered office: The Old Courthouse, New Road Avenue, Chatham, ME4 6BE. Tel. 01634 838739  How to complete the ABC CHART ~ 11 ~ © The Challenging Behaviour Foundation. Registered charity no. 1060714. www.challengingbehaviour.org.uk ANTECEDENT BEHAVIOUR CONSEQUENCE A Location, people, activity B Describe what you C Registered office: The Old Courthouse, New Road Avenue, Chatham, ME4 6BE. Tel. 01634 838739 saw What did the carer do/how did the person react? Record the ANTECEDENT events (Things that Record a detailed description Record the CONSEQUENCES of the happened BEFORE the behaviour) of the actual BEHAVIOUR behaviour. (What happened AFTER) Record things such as: (what did it look like?). This This involves recording: involves documenting: Where was the person? Exactly what were they Exactly how did you doing? Provide a step-by-step respond to the Was anyone else around or had anyone just description of exactly behaviour? Give a step- left? what happened e.g. he by-step description Had a request been made of the person? ran out of the living room, How did the person Had the person asked for, or did they want stood in the kitchen respond to your something specific to eat or drink? doorway and punched his reaction? Had the person asked for, or did they want a head with his right hand Was there anyone else specific object or activity? for approximately 1 around who responded Had an activity just ended or been cancelled? minute to or showed a reaction Where were you? What were you doing? to the behaviour? How did the person’ s mood appear? E.g. happy, sad, withdrawn, angry or distressed Did the person’ s behaviour result Did the person seem to be communicating in them gaining anything they did anything through their behaviour e.g. I want/ not have before the behaviour was don’ t want something? exhibited, e.g. attention from Were there any obvious triggers e.g. too noisy, somebody (positive/negative); an sitting on own for some time? object; food or drink; or escape from an activity of situation? Appendix 2 Are there any obvious setting events e.g. feeling ill, bad night’ s sleep, missing their mum or dad?  Example of how to observe behaviour, with a bad example and a good example shown ~ 12 ~ © The Challenging Behaviour Foundation. Registered charity no. 1060714. www.challengingbehaviour.org.uk DATE TIME ANTECEDENT BEHAVIOUR CONSEQUENCE POSSIBLE REASON/ Location, people, Describe what you What did the carer PURPOSE Registered office: The Old Courthouse, New Road Avenue, Chatham, ME4 6BE. Tel. 01634 838739 activity saw do/how did the person react Bad AM Asked Tom to Temper Tantrum. Told off. Out of the blue example clean up a drink He is aggressive he had spilt. Spoilt Monday Wants his own way. Good 9.15am Tom got up late Tom looked John shouted ‘ No’ Tom had a poor night’ s example and the bus was confused; he loudly and asked Tom sleep. waiting for him, made a loud to stop. John is new. Monday radio was grunting noise Tom ran out of the Tom did not understand what 6.11.09 playing, toast and grabbed kitchen crying. John was asking him to do. was burnt, John John’ s glasses. Tom was trying to escape from (new staff) the kitchen when he asked Tom to accidentally knocked the glass finish his over. breakfast. Tom spilt his drink. John asked Tom to clean up the Appendix 3 mess.