Preventing Challenging Behaviour

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Preventing Challenging Behaviour
Challenging Behaviour-National Strategy Group
25.4.2009

• David Allen, Anton Dosen, Eric Emerson, Craig
  Kennedy, Paul Langthorne, Peter McGill Bruce
  Tonge

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Epidemiology

• Combined prevalence rates for challenging
  behaviour mental health difficulties in people
  with intellectual disability 16- 41 (Cooper et
  al, 2007)
• Challenging behaviour accounted for 32-50 of
  reported difficulties
• Combined prevalence translates to 5-14 million of
  the worlds population
• 2-7 million with challenging behaviour?

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Impacts

• People themselves exclusion, institutionalisation
  , deprivation, physical harm, abuse,
  misdiagnosis, exposure to ineffective
  interventions.
• Carers physical harm, physical psychological
  ill health, increased burden of care and
  financial consequences, reduced quality of life.
• Commissioners/policy makers/providers escalating
  costs, policy undermined, high staff sickness
  turnover, service breakdown, scandal exposés.

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Challenging behaviour is

• Relatively common
• High impact (social, clinical, fiscal)
• Long-duration

Significant Direct Indirect Lifetime Costs
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Public Health Model

• Primary Prevention impacting on the incidence of
  a condition by changing or altering exposure to
  the factors that cause it (immunisation for
  rubella, sun screen for cancer, plastic beer
  glasses for violence, adoption of healthy
  lifestyles for coronary disease)
• Secondary Prevention screening for a condition
  before it becomes symptomatic and intervening
  early to reduce the likelihood of it developing
  (screening for cervical cancer, screening for
  high cholesterol modifying diet/using statins)
• Tertiary Prevention providing intervention to
  individuals who already have a condition in order
  to prevent further disability and restore
  pre-morbid functioning (insulin for diabetes,
  psychotropic medication for psychosis)

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Risk Markers for Challenging Behaviour

• Environmental
• social deprivation
• sensory material deprivation
• high levels of unpredictable stress
• repeated illnesses
• inconsistent practice
• high rate demands
• differential reinforcement of challenging
  behaviour
• high expressed emotion

• Personal
• male gender
• severe-profound ID
• secondary disabilities (communication, mobility)
• certain behavioural phenotypes.

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Primary Prevention of Challenging Behaviour

• Reducing exposure to known risk
  factorsReducing social deprivationProviding
  enhanced social material environmentsImproving
  general health careHigh densities of positive
  reinforcementWidespread use of proven
  instructional technologiesRoutine use of
  antecedent management strategiesRobust
  organisational infrastructures
• Coaching the development of more efficient
  alternate adaptive behavioursCommunication
  skills trainingCoping skills training
• Targeting of at risk groupsMalesSevere-profound
  IDSecondary disabilitiesBehavioural phenotypes

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Secondary Prevention of Challenging Behaviour

• Routine behavioural screening for those not
  already receiving intervention
• Early behavioural intervention (Wacker 1998
  Kurtz et al, 2003 Reeve Carr, 2000 McEachin
  et al, 1993 Dunlap et al, 1991)
• Critical periods? (Fenske et al, 1985)
• Providing enhanced practical and emotional
  support to carers

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Tertiary Prevention of Challenging Behaviour
Applied Behaviour Analysis
Social Role Valorisation
Person Centred Approaches


Behaviour Change Strategies
POSITIVE BEHAVIOURAL SUPPORT AS A SERVICE SYSTEM
Behaviour Management Strategies
Attention to mediator variables
Attention to implementation and management process
Achieve Behavioural Change
Improve Quality of Life
Reduce Risk


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Issues

• Present focus is on tertiary intervention-
  illogical (and incomplete)
• Need to reconceptualise challenging behaviour
  within a public health model of prevention
• Strategic approach-political issue
• Embed key elements within existing strategies?
• Making use of existing frameworks (e.g. Care
  Standards)
• Consequences of not acting
• Cost-benefit Research