The following short blog post is a summary of Hastings et al (2013). The full reference is at the end of the post
To be able to define Positive Behavioural Support (PBS), explain PBS interventions and clarify the competencies needed to support PBS, a clear conceptual framework is needed to identify why challenging behaviours are more likely to be engaged in by people with intellectual disabilities.
That was the task set out by a group of academics in 2013 (Hastings and others). This framework explains how certain vulnerabilities in a person’s life can trigger challenging behaviours which then continue to exist and are strengthened due to other people (parents, carers, etc) inadvertently responding in a way which may ‘reward’ the behaviour.
What is Challenging Behaviour?
Is challenging behaviour the noisy neighbour who plays the drums? Or the pupil who puts her hand up in class? Or the person who hits other people? We need to consider the social context and the potential social impact. Is it culturally inappropriate? Does it stand out from the social norm? Does it occur frequently at a high enough level of severity, or for a long enough time that there are clear social consequences (harm to self, others, or both)?
The drummer’s behaviour won’t be challenging if only played at lunch time, once a week. Yet the pupil’s behaviour may challenging if it’s done so often that it disrupts the class and as a result she is no longer asked to participate. And hitting other people is not viewed as challenging if it’s in a boxing ring…that’s why understanding the social context is key to defining behaviours that challenge.
- Biological Vulnerabilities
To understand what triggers behaviours that challenge, Hastings and colleagues emphasise the importance of ruling out physical health or sensory causes before analysing and assessing a behaviour that challenges.
A person may struggle to follow instructions in a community setting due to limited hearing, but without knowing this care givers may believe the individual is being stubborn or has an ‘attitude’. Someone may repeatedly hit themselves in the ear due to an ear infection (pain is temporarily dulled due to release of endorphins after being hit) but without knowing this, carers may believe the individual is “attention seeking” or doing it “out of the blue”. There could also be vulnerabilities due to a genetic influence. It is recommended that a physical health screen is conducted alongside, or before, any assessment of challenging behaviour. Ruling out physical health or sensory causes is important.
- Psycho-Social Vulnerabilities
Other triggers can include external vulnerabilities in a person’s environment. The Hastings paper classifies five main factors within psycho-social vulnerabilities which people with intellectual disabilities are more likely to experience. These are ‘negative life events’ (including trauma and abuse), ‘lack of communication skills’, ‘impoverished social networks’, ‘lack of meaningful activity’ and ‘general mood problems’.
- Increased exposure to negative life events, such as bullying, illness, bereavement and unpredictable staffing support systems predict increased risk for challenging behaviour.
- If a person has limited communication skills they may be forced to use other means, such as behaviours that challenge, to get the people around them to respond or to attend.
- Smaller and impoverished social networks lead to increased risk of abuse, reduced protection and increased risk of depression and loneliness.
- Lack of meaningful activity also increases risk of depression.
- People with intellectual disabilities appear to have an increased risk of depression and this may be linked with limited communication skills which makes it difficult to self-report mental health symptoms.
- Functions of behaviour
Why do challenging behaviours continue to occur? Why do people with intellectual disabilities continue to use behaviours that challenge which may be harmful to themselves or others? Hastings and colleagues state that these behaviours must be useful in some way to the individual, the behaviours must be serving a ‘purpose’ i.e. the behaviour must have a function.
In behavioural science, there are four (and only four!) functions of behaviour:
- Social attention
- Avoidance/Escape (including escaping pain)
- Access to tangibles (items, activities, places)
- In situations of low attention, if other people (a parent or carer) respond to challenging behaviour by attending (e.g. with sympathy, or with a rebuke), the behaviour may be more likely to occur in situations of low attention in the future.
- If other people make demands (e.g. ask a person to engage in a task) but then remove the demand when challenging behaviour occurs, challenging behaviour is likely to occur again in the future when demands are presented so that they can be avoided.
- Engaging in challenging behaviour can sometimes simply lead to stimulation and if so, may occur again when someone is ‘bored’.
In reality it’s not always as black and white as above. In most cases, challenging behaviour may be serving multiple functions such as gaining attention as well as escaping demand. Or accessing tangibles AND accessing attention. Or any other combination!
- Other people
For a person with an intellectual disability, the people within their immediate environment are often responsible for the individual’s quality of life. They ultimately have the power to increase or unintentionally decrease social contact, meaningful activity, access to health needs, and access to attention, tangibles or escape from demand.
In other words, the behaviour of other people in the immediate environment is extremely important, and extremely powerful. If done correctly and ethically, parents and carers have the power to increase a person’s quality of life and independence to the extent that challenging behaviour may be eradicated. However, without a full understanding of why the challenging behaviour is happening, they also have the power to worsen it.
A carer may be accidentally ‘increasing’ an individual’s challenging behaviour as they don’t have an accurate picture of what’s going on. Hastings and colleagues list some of the possibilities;
- They may have certain beliefs and attitudes which are inaccurate and may believe “she’s just doing it for attention” and decide to ignore her every time she throws a chair. But maybe this challenging behaviour occurs because she knows that every time she throws a chair her carers leave her room and she gains the much needed space she wants but hasn’t been taught to ask for.
- A carer may find challenging behaviours aversive and want to try and stop them any way they can by removing demand, soothing the individual, or giving them a little treat to help them calm. But maybe the individual bangs his head as he gets the quality attention he wants from one of his carers.
- Due to the challenging nature of supporting a person whose behaviour may be challenging, carers may often have heightened levels of stress. These stress levels mean that carers are more likely to respond to behaviours that challenge with lower levels of patience.
- A family unit will have their own parenting practices including how a single parent or a couple approach parenting, and the extent to which they have access to outside help or support.
Redstone Tips from the Hastings paper.
- Vulnerability factors can be targeted directly to reduce the likelihood of challenging behaviour occurring. For example, teaching social and communication skills or increasing engagement in meaningful activity will be important PBS interventions.
- Carers and staff teams need to understand how they have become stuck in a cycle of responding to behaviours that challenge. Functional behaviour assessment is needed to help with this and ensure function-based intervention addresses the maintaining processes.
- While medication might have a small role, even if only temporarily, the overwhelming focus is on social environmental and psychological factors, especially the behaviour of other people, staff and carers.
Reference: Hastings R. P., Allen D., Baker P., Gore N. J., Hughes J. C., McGill P. et al.(2013) A conceptual framework for understanding why challenging behaviours occur in people with developmental disabilities. International Journal of Positive Behavioural Support 3, 5–13.
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Sarah Hobson – Assistant Behaviour Analyst
Sarah has worked in the field of applied behaviour analysis and positive behaviour support with children and young adults with autism for five years. She initially gained her training whilst working at a specialist in London; progressing from a Trainee Tutor to a Senior Tutor before moving onto working on early intervention programmes for specific children in their home settings. Sarah’s main strengths include working on early intensive behavioural interventions, delivering functional communication training interventions (such as PECs, Proloquo2go or Makaton), working with those who engage with behaviours that challenge, and delivering skill building programmes. Sarah has an MSc in Applied Behaviour Analysis at Bangor University and is working towards gaining her BCBA qualification to become a qualified behaviour analyst.
Kate Strutt – Director of Redstone PBS and Clinical Psychologist.
Kate has over 20 years’ experience of working with adults and children with intellectual disabilities and those who are autistic, both within statutory services and the independent sector. Kate is registered with the Health and Care Professions Council. Bsc Psychology, D.Clin Psyc, MSc Applied Behaviour Analysis.