Challenging Behaviour: How to Avoid Kicking the Cat

I ran a course yesterday for Residential Care Staff. The imaginatively titled Challenging Behaviour and Dementia course is always interesting in that it reminds me of some of the difficulties care staff have to face, even working with elderly clients. As always, the story of the course is that even little old Doris (85) can and does pack quite a punch when she wants to!

Now according to Google there’s an awful lot of people typing ‘challenging behaviour’ and ‘challenging behaviour definition’ into the little white box, which means if you’re here right now you’re a) writing up a college project or b) working with a bunch of service users/patients/clients who are posing difficulties of one form or another.


Now, I know how it works with students. You just want something quick and dirty to cut and paste into your Word Processor. Yep, been there. So if you just want a definition, here it is. In fact, here’s two!

Definition 1: ‘any behaviour which negatively effects both the ’perpetrator’ and those around them to a significant and/or frequent degree’ (Kinsella 2010)

Definition 2: Culturally abnormal 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 use of, or result in the person being denied access to, ordinary community facilities (Emerson 1995)

If that’s fulfilled your essay needs, glad to be of service. Bookmark this page and we may see you again ….

Otherwise, hang on in there.  We’re going to outline some of the key skills we need in dealing with the sort of challenging behaviour which can be problematic, highly unpopular, scary and generally pretty awful, often to the point where we really don’t want to go into work and face another shift. But challenging people with challenging behaviours are no less deserving of our efforts than anyone else, so let’s take a brief look at some of the stuff from the JCK Training Managing Challenging Behaviour course which I hope might be helpful and even save you that extra bottle of wine/shouting at the TV/shouting at family and those occasional feelings of wanting to put our heads through a wall. And of course, we want to avoid kicking the cat. Working with Challenging Behaviour is’nt easy.

The nature of challenging behaviours presented by an elderly care home resident may be very different from those presented by, for example, a young person with borderline personality disorder, but the way we are going to approach the behaviours does not change – we are going to try and replace instinctive, reactionary responses with a more systematic, model-based approach. But first we need a few basic assumptions.
  1. Any service user (or human being for that matter) has the potential to behave in ways which are anti-social, aggressive and likely to have a negative impact on themselves and others. In fact, think of the last time you phoned a call centre. After spending five minutes listening to Greensleeves (no, bloody Greensleeves) interspersed with the patronising grind of ‘your call is important to us but please hang another minute while we make another £4 billion out of your sorry arse’ before eventually getting to speak to a human being called Malcolm, you are probably going to feel like telling Malcolm to shove his headset somewhere dark and possibly a bit damp. See? We can all get a bit challenging sometimes.
  2. The service user is at the heart of our discussion, assessment, planning and evaluation. This may appear to be a statement of the obvious but once a challenging individual has become associated with aggression or worrying behaviour (or put less technically, ‘scared the crap out of us’) that person can easily become marginalised and begins to drift further and further from involvement in their own care. We shall try to avoid this as much as possible although it’s fair to say that some service users will never be able to participate in their own care. In which case a family member or nearest relative  will hopefully be only to glad to be involved. 
  3. It may seem at first glance that a person with severe cognitive impairment caused by dementia or a learning disability behaves in unpredictable, random ways, but all human behaviours occur for a reason and attempting to identify why challenging behaviour occurs is a key aspect of our project.
  4. We are not aiming to ‘cure’ the service user of their challenging behaviour. We are simply aiming to reduce the severity and frequency of the target behaviour so that life is better for the service user and people around them.
  5. Our final assumption is that the advice offered here can offer generic principles of good practice and a guide to using a structured approach. However, there are no magic wands. Local conditions, client characteristics, resources and restrictions will all govern how challenging behaviours are defined and recognised locally, and how we go about managing these behaviours.


The CAPEd (sic) Crusader
In our Challenging Behaviour course we introduce a framework for working with challenging behaviour. Like all frameworks or models we tried to come up with a sexy acronym to help you remember the various bits, but all we could come up with was CAPE

Yes, BANG, WHIZZ or KAPOW might have been more appropriate (and sexy) but the letters didn’t fit. So we have CAPE. So what does CAPE stand for?

  • Clarification
  • Assessment
  • Planning
  • Evaluation


Let’s take  look at these stages and what they mean for us.

Clarification
We start by asking the question: What is the behaviour? This may at first sight appear a simple and straightforward task, but there are some common pitfalls especially when writing down or recording an incident in a service user’s notes or in untoward incident documentation.  We need to be careful here to actually describe the behaviour, not the emotion behind it. 

Writing ‘he got very angry’ in your notes is a description of how he feels, not of the behaviour itself. Right now we need to simply record what has actually ‘happened’. For those of a grammatical bent, we need ‘verbs’ not ‘adjectives’.
We also need to be aware of the possibility that an incident we are trying to describe may become the subject of further investigation, for example by the police or by a safeguarding vulnerable adults panel, so detail is good. Very good.

A key determining factor in where we go next is whether a behaviour meets a stated definition of challenging behaviour. We have defined challenging behaviour above but of course I’m here and you’re there. Local circumstances and environment will be key in determining what is significant or frequent enough to warrant further assessment and perhaps an action plan.  A person banging their head against a wall or shouting at a support worker will be seen in quite different ways in different environments, which in itself will demand quite different plans and interventions.

Assessment
The first stage of our framework has asked the ‘What’ question. Our Assessment stage is where we attempt to look at the Who and Why and How questions, so perhaps we are going to get our hands a little ‘dirtier’ in this stage. But the effort expended will be well worth the effort as we attempt to address problem behaviours rather than simply accepting, putting up with or condemning them.

So where do we start? Hopefully with a clear and concise description of an incident or series of events based on our Clarification stage, but remember this is a structured, proactive approach to challenging behaviour and there are some key questions we may wish to ask:
  1. Is there Consensus within a staff team that what has been observed constitutes challenging behaviour according to an agreed definition or baseline?
  2. What is the Frequency of the behaviour? Are we looking at a standalone event or one of a series of incidents?
  3. What is the Impact of the behaviour? Ask the same question of the service user him or herself, and depending on location and circumstances, support staff such as yourselves, family members, neighbours or other.  Or couched in other words, who were the victims of the behaviour and how are they affected?
  4. If a there is a Victim as such including of course, the perpetrator(s), what are their characteristics? This is particularly important if there is a regular pattern to the challenging behaviour.
  5. Is there a Pattern of behaviour? In residential care for example, mealtimes are often a flashpoint for confrontation. Over a longer period of time, seasonal changes may be important or incidents may be seen to occur at a particular time of day.
  6. Is there a Precipitant for a person’s behaviour other than those we have already mentioned? Remember our starting position that behaviour almost never occurs purely at random regardless of the cognitive or functional abilities of the perpetrator. 
  7. Drugs and Alcohol. It may be a question of judgement whether or not we refer to substance use or misuse, but most of us are more than familiar with the association between intoxication and self-destructive or anti-social behaviour.  Our assessment may require more than a simple association between, for example, a client’s habit of drinking a four-pack of nuclear strength lager for brunch and his or her subsequent hostility on home visits, but it is always attempting to assess exactly how and why a substance affects the perpetrators behaviour as opposed to simply stating that ‘they get angry when drunk.’

The above is just a small selection of areas we might want to examine during our assessment, but our most useful tool is our own knowledge and rapport with the people with whom we work, and let us not forget that often the best informant of all is of course the person presenting the challenging behaviour. I often find when running courses that the most obvious question of all hasn’t been asked of the challenging individual: Why do you do it? This isnt always an easy question to ask depending on the individual and the circumstances, but can (if put skilfully and non-judgementally) yield surprising results. 

Planning
This is our ‘doing’ or ‘intervention’ stage. Whether we are referring to ‘Action  Plans’, Care Plans’, Support Plans’ or any other terminology which essentially means the same thing, most health and social care organisations have some form of written plan which clearly states what we are hoping to achieve and do with a service user.

We need clear consensus between ourselves as a staff member, our colleagues and collaborators from other agencies (such as professionals from Primary Care Trusts or Social Services or supported housing) as to how we describe challenging behaviours, our assessment and how we are going to respond. If and when appropriate, our planning should include as an essential of best practice a clear collaboration between ourselves and the service user.
Remember one of our initial assumption s from our very first page: we are not attempting to ’cure’ the perpetrator or change his or her personality, but simply reduce the frequency of challenging behaviours, the impact of those behaviours on others and themselves, or preferably both.
Evaluation
By now we have hopefully concluded that a consensual, structured, proactive approach to challenging behaviour is more likely to achieve our outcomes than staff response which is haphazard, reactive and fuelled by panic, fear or resignation. There is always the potential for staff who work regularly with challenging behaviours to become ‘over sensitised’ to verbal or physical aggression, self harm, destruction of property or any other of the challenging behaviours we have identified and set out to manage. 

Evaluation is a means of at least trying to ensure that we see worrying or dangerous behaviour for what it is, and whether we are are constantly evaluating informally over a cup of coffee with colleagues and service users, or more formally through meetings and reviews, our intention is to review the outcomes of our Plan in terms of impact, frequency and quality of life, add to our assessment and look toward the short and long term future which will hopefully mean a much better quality of life for service users, and a less worrying time for your cat. 
Emerson, E. (1995) Challenging Behaviour. Analysis and Intervention in People with Learning Difficulties Cambridge: Cambridge University Press.

Kinsella, C. (2010) Working with Challenging Behaviour JCK Training



Visit JCK Training for details of health and social care in-house courses, including Working with Challenging Behaviour

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