Definition
The term challenging behaviour was adopted from The Association for Persons with Severe Handicaps (TASH), and emphasises that behaviours represent challenges to services, rather than problems which are solely intrinsic to the individuals with learning disabilities. Emerson et al (1987) suggests the following as a definition of severely challenging behaviour "Severely challenging behaviour refers to behaviour 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 or delay access to and use of ordinary community facilities"
Although behaviours may not always be life threatening, they can significantly interfere with the quality of life of the individuals concerned, and that of those who live with and care for them. Challenging behaviours may include aggression, both verbal and physical, self-injurious behaviour, non-injurious stereo-typed behaviours. A number of studies have attempted to describe the extent or prevalence of challenging behaviour. There are a number of difficulties in answering this question however. The term 'challenging behaviour' is socially defined, and what is registered as extremely challenging in one set of circumstances and for one set of staff, may not be defined as such in any other. For a more detailed discussion of these issues see Qureshi (1994).
Policy
Two key publications from the Kings Fund set out a framework for developing high quality services for people with challenging behaviour (Facing the Challenge), and provided examples of these in practice (Meeting the Challenge). The Kings Fund publication 'Facing the Challenge; An Ordinary Life for People with Learning Difficulties and Challenging Behaviour' (Blunden 1987) was an influential document in developing a framework for service development. Each of the services described in these documents took an approach based on individual needs, using a person-centred approach, combining aspects of behavioural approaches with counselling related approaches.
In 1993, the Department of Health published 'Services for People with Learning Disabilities and Challenging Behaviour or Mental Health Needs.' The project group was chaired by Professor Jim Mansell, and the document became known as the Mansell Report. The Mansell report identified five key themes:
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The social context of challenging behaviour.
That is that challenging behaviour is the product of the interaction between individual factors, and the circumstances in which people live. Responding to challenging behaviour in any locality will require responding to the individual and their social context.
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The importance of management commitment.
Challenging behaviour is a leading cause of 'placement breakdown', and services for this group of people use significant resources. The report suggested that priority should be given to people with challenging behaviour because although the numbers may be relatively small, people with challenging behaviour often have the greatest needs. The report argued from its examination of four 'exemplary services' that good quality services achieve results and that failure to develop services locally could threaten the policy of community care for people with learning disabilities.
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The service development process
The report argued that those with a responsibility for commissioning services should have clear strategies for ensuring that agencies providing services have adequate numbers of suitably trained staff to provide comprehensive service responses. Responsibility for supporting people between local health and social care agencies was best defined in relation to the relative skills and experience of each agency locally, rather than to any pre-defined notional boundary between health and social care responsibility.
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Empiricism and cost constraint
The four 'exemplary services' described in the project report were all developed within existing resources in the service areas. Commissioners should ensure that all costs are taken fully into account when determining strategy and alternative responses, including 'hidden costs', for example responding to crises and placement breakdowns, and the financial and other costs borne by carers.
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Comprehensiveness
The report suggested joint commissioning as a possible way for health and social services commissioners to work together, emphasising the inter-dependency of the different components of the service system. The report went on to make 26 recommendations for service development, and to establish an implementation network.
Implementing Policy
Following the publication of the report, Mansell (1993) went on to suggest a practical framework for operationalising the recommendations of his report. He suggested that the goals of services for people with challenging behaviour should be:
"...to provide placements which minimise the occurrence of challenging behaviour, to maintain sufficient placements with resilience and capability to cope with challenges that will be faced."
He identified four sub-systems of activity which should be attended to by service providers to deal with the small number of people, well known to the service who present the most serious challenges, as well as those who, given the right social, physical, environmental and individual needs setting events, have a high probability of displaying challenging behaviour. The four sub systems were identified as:
- Prevention: enriched environment, staff organised to promote adaptive behaviour
- Early detection: detecting emerging problems, danger signs in 'successful' placements
- Crisis Management: contingency planning, respite services, skilled intervention, access to new homes and jobs
- Specialised Long Term Support: sophisticated individualised help; high levels of technical and emotional support for staff
References
Allen D, Banks R & Staite S (Eds) (1991); Meeting the Challenge: Some UK Perspectives on Community Services for People with Learning Difficulties and Challenging Behaviour, Kings Fund, London
Blunden R & Allen D (1987); Facing the Challenge: An Ordinary Life for People with Learning Difficulties and Challenging Behaviour, Kings Fund
Department of Health (1993); Services for People with Learning Disabilities and Challenging Behaviour or Mental Health Needs, The 'Mansell Report', HMSO, London
Emerson E, Barrett S, Bell C, Cummings R, McCool C, Toogood A & Mansell J, (1987) 'Developing services for people with severe learning difficulties and challenging behaviour: Report of the early work of the Special Development Team in Kent',
Jacobsen JW (1982) "Problem Behaviour and Psychiatric Impairment Within a Developmentally Disabled Population, Behaviour Frequency", in Applied Research in Mental Retardation, 3, pp121-39
Mansell J (1993); Policy and Policy Implcations, in in Severe Learning Disabilities and Challenging Behaviours, Eds Emerson E, McGill P and Mansell J, Chapman & Hall
Qureshi H (1994) 'The Size of the Problem' in Severe Learning Disabilities and Challenging Behaviours, Eds Emerson E, McGill P and Mansell J, Chapman & Hall
