DRAFT
1
An Investigation into the topography
of referrals to a Community Challenging Behaviour Service: Implications
for research and training
Andrew McDonnell, Clinical
Psychologist
Lucy Knight, Assistant Psychologist
Paul Manning, Assistant Psychologist
Janet Hardman, Clinical Psychologist
Community Challenging Behaviour
Service
The Greenfields
B30 3QQ
Abstract
This study examines 50 referrals to a specialist challenging behaviour service, to ascertain the most frequent forms of aggressive behaviour presented and the qualitative differences that exist within them. Information was collected from interviewing key staff using a revised version of the Checklist of Challenging Behaviour (CCB), and from recording specific details of the behaviour that were described. A hierarchy of the most frequent aggressive behaviours exhibited was found, with the most common behaviours being “grab, push, pull”, “hitting out (with open hand)”, “kicking” and “self injurious behaviour”. This is consistent with other studies in the field. More microscopic analysis showed that eight service users accounted for 24% of the overall management difficulty score, despite accounting for a much smaller proportion of the overall frequency and severity scores. Many qualitative differences appear to exist in respondent’s subjective interpretation of the categories used in the CCB. The implications for the development of training in the physical management of challenging behaviour are discussed.
Introduction
Aggressive
behaviours can evoke powerful emotional responses from care staff
(Singh, Lloyd & Kendall, 1990; Bromley & Emerson, 1995; Ager
& May, 2001). Despite a relative plethora of studies which review
behavioural outcomes (Didden, Duker
& Korzillius 1997; Ager
& May, 2001; Allen, 2001) our knowledge of the physical manifestations
of aggression is relatively limited (McDonnell, 2002).
Staff
who work with people with LD are at a relatively ‘high risk’ of encountering
violence (Kiely & Pankhurst, 1999). Physical
aggression tends to be the most common form of challenging behaviour
referred to specialist behaviour support teams (Maguire & Piersel, 1992). Aggressive and violent behaviours give rise
to injury to carers and peers (Hill & Spreat,
1987) and may in some circumstances be associated with high staff
turnover and lower job satisfaction (George & Baumeister,
1981; Razza, 1993), although more recent
evidence suggests that the relationship is complicated (Murray, Sinclair,
Kidd, Quigley & MacKenzie, 1999; Hatton,
Emerson, Rivers, Mason, Swarbrick, Mason,
Kiernan, Reeves, & Alborz, 2001). Furthermore,
these behaviours may result in injury to service users when attempts
are made to restrain them and may provoke physical abuse from carers
(Rusch, Hall & Griffin, 1986; Baker & Allen, 2001).
There
have been attempts to quantify aggressive behaviours among people
with LD (Qureshi, Alborz, 1992; Emerson,
Kiernan, Alborz, Reeves, Mason, Swarbrick,
Mason & Hatton, 2001). Emerson
et al. (2001), in a total population survey, found the most common
physical behaviours to be ‘hitting others with hands’ and ‘hitting
others with objects’. Joyce,
Ditchfield & Harris (2001) reported
‘hitting’ and ‘grabbing’ as their most frequently occurring behaviours.
Allen (2000) stated that most incidents seemed to involve “single
punches, slaps and kicks”. He also argued that weapons may be used
by between 17-29% of individuals who present with aggressive behaviours.
Data does not really exist in the literature to verify this claim,
and there is little information available on the types of weapons
used.
It has been argued in the literature that there were qualitative differences in violence manifested with people with LD (McDonnell, Dearden & Richens, 1991). The assumptions of such a premise imply that physical behaviours shown by people with LD may be less “street-wise” than that which is presented in the general population. It is also assumed that many physical assaults on staff may form a bimodal distribution; with behaviours ranging from serious assaults with weapons causing harm to a person, through to a “one-off slap or punch” with little harm caused. At present there appears to be only anecdotal evidence to support these assertions.
Detailed
information about the physical manifestations of aggression are
important for the development of reactive strategies and staff training
(Harris, Allen, Cornick, Jefferson &
Mills, 1996; McDonnell, 2002). Staff training in physical interventions
has been acknowledged to develop staff confidence (Allen, 2001; McDonnell,
1997). It is concerning that the content of such training
has received little attention in the literature (Allen, 2001). What physical skills should be taught to direct
care staff? To answer this
question adequately detailed information is required about the physical
manifestations of aggression. Detailed information should also lead
to the development of reactive strategies (LaVigna
& Donnellan, 1986) which aim to reduce the frequency and intensity
of behaviours. An evidence based approach to training in reactive
strategies is important given the proliferation of behaviour management
training. (Allen, 2001)
The aim of this study was to provide detailed microscopic analysis of the physical manifestations of aggression. First, to ascertain the most frequent forms of aggressive behaviour. Second, to examine the qualitative forms of aggression reported by care staff. Third, the implications for designing staff training in the management of aggressive behaviours will be discussed.
Materials and methods
Participants
The sample consisted of 50 individuals with LD (33 males and 17 females) between the ages of 17 and 65 years, with a mean age of 32.5 years (standard deviation of 10.49 years). Within the last three years, all were referred to the Community Challenging Behaviour Service, a city-wide tertiary service which is part of Birmingham Specialist Community Health NHS Trust. The majority of referrals contained physical aggression as a component of the presenting problem.
Measure
The Checklist of Challenging Behaviour (CCB: Harris, Humphreys & Thomson, 1994) is a 34 item checklist which was developed as a survey instrument in a study of aggressive behaviour amongst individuals with learning disabilities. It has been used in population surveys in community services (Joyce, Ditchfield & Harris, 2001).
The original checklist contained items which were collapsed categories “Punching, slapping, pushing or pulling”. It was found that these categories required separation, and new categories of “Hitting Out (with open hand)”, “Punching Out” were added and “Pushing/ Pulling” was expanded by adding “Grabbing”.
The CCB includes 12 items which focus on physically aggressive behaviours presented by people with learning disabilities. All items are scored in terms of their frequency of occurrence, the severity of the injury caused, and the management difficulty that the behaviour poses to carers. Each of these dimensions are scored on a rating scale; The ‘frequency’ refers to how often the behaviour has occurred in the last three months, and ranges from (1) has not occurred to (5) occurs very often (daily). The ‘severity’ refers to the most serious injury caused by the behaviour in the past three months, ranging from (1) no injury to (5) very serious injury (caused very serious tissue damage (e.g. broken bones, deep lacerations/ wounds) requiring hospitalisation and/or certified absences from work). ‘Management difficulty’ relates to how difficult the carers find the behaviour to manage and is scored on a scale of (1) no problem (‘I can usually manage this situation with no difficulty at all’) to (5) extreme problem (‘I simply cannot manage this situation without help’).
Procedure
All individuals who are referred to the Community Challenging Behaviour Service have the CCB administered by trained staff, as part of the screening criteria for the service. The CCB forms the basis of a semi-structured interview which is normally carried out with the service user’s primary carer. Where carer’s reported incidents of physically aggressive behaviour, interviewers were encouraged to record specific details of the behaviour.
Results
A Chi-square test of independence was conducted to see if there were any significant differences between males and females. No significant gender differences in the manifestation of physical aggression was found (x2 0.603, df = 1, p>0.05).
Table 1 compares the frequency of physical aggression in the current sample with that from a study by Joyce et al. (2001), who used the Harris and Russell (1989) CCB.
Table 1: Comparison of physically aggressive behaviours with Joyce et al. (2001)
|
Behaviour |
Percentage of current
sample |
Percentage of Joyce et
al. (2001) sample |
|
Grab/push/pull |
72% |
73% |
|
Hit Out (with open hand) |
72% |
49% |
|
Kick |
60% |
26% |
|
Injury to self |
54% |
37% |
|
Punch |
48% |
N/A |
|
Throw |
46% |
27% |
|
Pinch |
34% |
21% |
|
Scratch |
34% |
26% |
|
Weapons |
30% |
13% |
|
Hair pull |
24% |
N/A |
|
Bite |
22% |
9% |
|
Clothes |
18% |
8% |
|
Head-butt |
16% |
4% |
|
Choke |
16% |
5% |
There was a significant positive correlation between Joyce et al. (2000) and our data (Spearmans Rho. p<0.01) showing that the behaviours rated most frequent in our sample are most frequent in her study also.
The median frequency score for our data was 25/70 with a range of 14-50. The median management difficulty score was 24/70, with a range of 14-45. The median severity score was 21/70, with a range of 14-38.
A Spearman’s rank correlation demonstrated that there was a positive correlation between the Frequency and Management Difficulty of the physically aggressive behaviours (p = 0.93, n = 50, P<0.01). This is consistent with findings from other studies (Harris et al., 1994; Joyce et al., 2001). There was also a significant correlation between the Frequency and Severity (rs = 0.72, n = 50, P< 0.01) and Management Difficulty and Severity of the behaviours (rs = 0.89, n = 50, P<0.01), which were also identified by Harris et al. (1994). Visual inspection of Figure 1 demonstrates that sophisticated behaviours such as ‘Use of Weapons’, ‘Head-butting’, and ‘Choking/ Throttling people’ occurred least frequently in our sample. Correspondingly, ‘Grabbing/ Pushing/ Pulling’, ‘Hitting’, and ‘Injuring Self’ were most frequently reported.
Management difficulty ratings were not totally consistent with those for the frequency of behaviours. Behaviours such as ‘Hitting’, ‘Grabbing/ Pushing/ Pulling’, ‘Kick’, ‘Throwing Objects’ were rated by primary carers as the most difficult to manage, despite not all being the most frequently reported.
High Risk Service Users
The scores
of the eight service users who were rated as having the highest ‘management
difficulty’ were analysed. This demonstrated that these eight individuals
accounted for 24% of the overall ‘management difficulty’ score, 9%
of the overall ‘frequency’ score and 5% of the overall ‘severity’
score. There were no significant correlations between the management
difficulty, frequency and severity scores of the individuals rated
with the highest management difficulty scores (Spearman’s
Qualitative Descriptions
Qualitative differences exist in the categories of violence that are reported. There was a wide range of responses, a proportion (52%) of which are detailed in Table 2.
Table 2: Qualitative comments from Challenging Behaviour Checklists.*
|
Behaviour |
Comments |
|
Pinch |
“Because a service user tries to sit on him”, “Usually forearms” |
|
Bite |
“Usually due to constipation”, “When restrained or having personal care
done” |
|
Scratch |
“Hands/ arms”, “In passing” |
|
Hitting Out (open hand) |
“Retaliating”, “Will hit anyone, indiscriminately”, “At service users
more. Slapped service user across face. Gets a kick out of it”,
“Continuous light tapping”, “Hit once then runs”, “Once only,
so out of blue”, “Only occurs if he’s unoccupied”, “Open hand
towards face and head”, “As a game, giggles/ will wind people
up, knock them over”, “Fending people off”, “Intermittent unpredictable
punching, usually 1 blow”, “Attacks from behind and in middle
of back, single hit” |
|
Punching Out (clenched fist) |
“Does it when staff are not there”, “When confronted” |
|
Head-butt |
“High-risk. Directs front of head to face area causing injury to teeth,
nose and cheeks”, “When his other limbs are held”, “Will head-butt
mom, but doesn’t hurt and leaves no bruising”, “Windows in car”
|
|
Kick |
“When annoyed or moving his boxes”, “When loosing control”, “Only ankles”,
“Very quick, finds it funny”, “Situational” |
|
Using weapons |
“Anything, bottles, cups, boxes. At dinner table will go for someone
with knife and fork, with someone she doesn’t want to sit next
to”, “Uses sticks”, “At breakfast, stabbed other
service user in head”, “Lunges out with spoons or forks at mealtimes
if he’s given them”, “Chairs, light fittings. Can street fight”,
“Scissors”, “Mugs, glass objects, bricks, generally at staff”,
“E.g. broom”, “Cups and kettle once”, “Prods other service users
with cutlery knife”, “Whatever’s at hand”, “Chairs – when he’s
done scratching and kicking – last resort. He holds chairs up first”, “Picks up chair,
threatens to hit or throw. Pencils, rubbers, books”, “Chairs,
books”, “Cups, ornaments –will fling at you”, “Chairs, glass
bottles, he’s opportunistic”, “Anything: bottles, cups, boxes”
|
|
Throwing things |
“All the time (hourly), will use anything”, “Glass bottles/ boxes. Kicks
them more for effect”, “Slippers”, “Not aimed”, “Cigarette ends,
paper rubbish”, “Anything”, “Mug of milk or anything that’s
loose”, “Aims for the window, goes for maximum effect. Throws
things, but not at people”, “Small objects to hand”, “Clothes,
shoes”, “E.g. pillows, anything on the chair, she’ll throw on
the floor” |
|
Injuring self |
“Cuts to arms, friction burns, cigarette burns”, “Runs into walls/ doors-
immune to pain?”, “Scratches his skin, makes himself bleed”,
“Throws herself to floor, jumps in bath” |
|
Tearing clothes |
“When grabs”, “With zips, toggles and dangly bits” |
|
Choke/ Throttle |
“Not sustained, didn’t feel in danger”, “Grabs at peoples collars”,
“Has done it in temple to have fun, doesn’t really do it forcefully”,
“Arm around neck when saying hello, hard to get off” |
|
General |
“She appears to be aggressive but isn’t, she’s more playful” |
*Data from 26 Checklists
For example, looking at the behaviour of ‘Using Weapons’, there are inconsistencies in the nature of what is reported; One respondent describes an extreme incident which appears high-risk in nature: “At breakfast, he stabbed other service user in the head”. Whereas, another respondent describes a behaviour which, whilst challenging, seems less risky: “Prods other service users with cutlery knife”. Other inconsistencies can be identified for behaviours such as Head-Butting (“Directs front of head to face area causing injury to teeth, nose and cheeks” compared with “Will head-butt mum, but doesn’t hurt and leaves no bruising”), Hitting Out (“Attacks from behind and in middle of back, single hit” compared with “Continuous light tapping”), Throwing things (“Glass bottle/ boxes” compared with “Cigarette ends, paper rubbish”) and Injuring-Self (“Cuts to arms, friction burns, cigarette burns” compared to “Scratches his skin, makes himself bleed”).
A similar pattern was reported for the throwing of objects. Many of the statements from staff indicated that objects were quite rarely thrown directly at themselves or other service users. (‘throws things, but not at people’ ). Even behaviours such as hitting with an open hand or a clenched fist indicated a range of behaviours. Some of this were aimed at a part of the body which could potentially cause serious harm (‘open hand towards the face and head’) to behaviours which appeared to cause little or no physical damage (‘continuous light tapping’).
Discussion
The analysis revealed that there was a positive correlation between the frequency, management difficulty and severity of the aggressive behaviours. This indicates that as the frequency of the aggressive behaviours increased, so did the severity of the injury caused and the management difficult posed to carers. The frequency of aggressive behaviours was also relatively low. This is surprising given that majority of the referrals were for physical aggression to a specialist service. It has been acknowledged that there are difficulties in investigating aggression as many such behaviours tend to be low in frequency (Whitaker, 1993)
Twenty-four percent of the total ‘management difficulty’ score was accounted for by eight service users. However, these eight service users did not all display as high scores on the frequency or severity scales. For this small group of individuals, there is no consistent relationship between in the frequency, management difficulty and severity of behaviours displayed. It may be that these individuals warrant special attention in terms of helping staff manage such infrequent behaviours.
In accordance with Joyce et al. (2001), the data suggests there is a consistent hierarchy in the physically aggressive behaviours manifested by people with LD. The most frequent behaviours reported are ‘grab, push, pull’, ‘hit out (with open hand)’, ‘kick’ and ‘injury to self’. Behaviours such as ‘choking’, ‘head-butt’, ‘use of weapons’ are reported less frequently. Emerson et al. (2001) also found that ‘hitting others with hands’ was the most frequently reported physically aggressive behaviour however, comparisons are difficult due to differences in the way behaviours have been categorised. The most frequent behaviours were also consistent with findings from Allen (2000) who cited kicking and slapping as frequent behaviours. However, this study did not identify ‘single punches’ as being frequent as Allen suggested. The most frequently reported behaviours are ones which appear to require less physical co-ordination, seem to require less pre-planning in terms of execution and are not the most effective in terms of causing physical debilitation. This indicates that the physical aggression shown by a large proportion of people with LD is generally unsophisticated in nature.
There were qualitative differences in the physically aggressive behaviours reported. People’s responses in the ‘use of weapons’ category ranged from “picks up chair, threatens to hit or throw” to “stabbed other service user in the head”. ‘Throwing objects’ ranged from “glass bottles” to “pillows”. The qualitative differences could explain the unexpectedly high use of weapons in this sample (30%), which was previously identified by Allen (2000). It is apparent that there is a great deal of subjective interpretation in the categories used within the CCB. However, it does appear that there are a number of individuals who display more high-risk and sophisticated behaviours.
Staff training in physical interventions has been acknowledged to improve carer confidence (McDonnell, 1997). The range of responses reported in this study would be difficult to cater for in one training course. It may well be that two distinctive types of training are required for services for people who present with physical challenges. Training in physical interventions is often recommended to be designed around individual need (Allen, 2001). This data suggests that a small number of service users may require highly customised behaviour management plans. However, for the majority of service users, certain physical behaviours are consistently found to be occurring more frequently. This makes a strong case for the development of more generic physical intervention training around these high frequency behaviours. This study suggests generic training should include ‘grabbing, pushing, pulling’, ‘hitting out with an open hand’ and ‘self-injurious behaviour’. Behaviours which may not be appropriate for generic training might include ‘choking’ and ‘head-butting’.
It is important to interpret these results in light of some methodological limitations. First, data collected in this study was taken from referrals to a specialist challenging behaviour service, and may not reflect behaviour patterns within the more general LD population as a whole. In addition the sample of individuals used comprised of two thirds male to one third female. Although no gender differences were identified in the current study, it would be interesting to see if this remains stable with a more representative sample. Second, due to the retrospective nature of the study, the administration of the CCB was not consistent. It was administered by different members of the Community Challenging Behaviour Service and although this was usually done with the primary care giver, this was not always possible. The collection of qualitative information was also done on an ad-hoc basis. Third, the ratings on the CCB are subjective. Frequency ratings for behaviours could have been affected by respondents knowing that the CCB is used as a criteria for accessing the service. Many of the respondents may not have received any form of training in managing challenging behaviour, and may be struggling to work with challenging service users. This would have implications for their perception of the challenging behaviour and their ratings of it. Finally the most subjective item within the CCB is the ‘management difficulty’ rating. This could have been affected by the respondent’s perception of service user control and intent over their behaviour, their relationship with the service user and their personal tolerance levels for different behaviours. Despite the subjective nature of the CCB, and ‘management difficulty’ rating in particular, respondents’ opinions are crucial in terms of defining challenging behaviour and how to intervene as a specialist service.
This study has provided some limited information which has relatively clear implications for training in physical interventions. First, the range of physical behaviours presented by the service users in this study could not be responded to by developing one type of training course. Second, great care should be taken when interpreting care staff perceptions of problematic behaviours. There are clearly differences between someone throwing an object at an individual in contrast to throwing an object ‘blindly’ around a room. Third, this data set should not be viewed as a ‘green light’ for the need for physical interventions training. Training in itself is not a panacea (McDonnell, 1997), future research is needed to accurately assess whether staff training in this area can have an affect on staff perceptions of behaviour, staff/service user injuries and confidence in managing these behaviours.
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Appendix
Table 1: Comparison of physically aggressive behaviours with Joyce et al. (2001)
|
Behaviour |
Percentage of current
sample |
Percentage of Joyce et
al. (2001) sample |
|
Grab/push/pull |
72% |
73% |
|
Hit Out (with open hand) |
72% |
49% |
|
Kick |
60% |
26% |
|
Injury to self |
54% |
37% |
|
Punch |
48% |
N/A |
|
Throw |
46% |
27% |
|
Pinch |
34% |
21% |
|
Scratch |
34% |
26% |
|
Weapons |
30% |
13% |
|
Hair pull |
24% |
N/A |
|
Bite |
22% |
9% |
|
Clothes |
18% |
8% |
|
Head-butt |
16% |
4% |
|
Choke |
16% |
5% |
Table 2: Qualitative comments from Challenging Behaviour Checklists.*
|
Behaviour |
Comments |