Challenging behaviour and behaviour support models
People with intellectual disabilities (ID) can often have diverse and complex needs in terms of behaviour, health, emotional and social functioning (Alim 2011). It is known that people with ID are three to four times more likely to suffer from a range of psychiatric and behavioural disorders than the general population (Al-Sheikh 2011); people with ID have been found to have higher rates of certain psychiatric illnesses than the general population (Deb, Thomas & Bright 2001a), and behavioural disorders as prevalent as 60-4% in community settings (Deb, Thomas & Bright 2001b). Behavioural and psychiatric disturbance can result in presentations of challenging behaviour, which have been defined as: ‘culturally abnormal behaviour(s) of such 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, cited in Emerson 2001).
Historically, the management of challenging behaviour was mainly through the use of high-secure institutions and psychotropic medications (Benson & Havercamp 2007). Since the 1960s, behavioural interventions have been developed which have aimed to identify the function of challenging behaviours, and to utilise the principles of reinforcement to make these behaviours less likely to occur. Some controversies have surrounded behavioural approaches, especially around the use of punishments or negative consequences to reduce problem behaviours (Emerson 2001). As a result of this, and the emergence of the ‘social model’ of disability (AAIDD 2010), behavioural practice has changed dramatically to a systems-based approach known as positive behaviour support, an intervention which addresses environmental conditions and an individual’s skill deficits, as well as reinforcement, in order to reduce challenging behaviours. There have also been a broad range of psychosocial interventions developed and researched which aim to increase an individual’s engagement with their community, for example, through supported employment, educational intervention and skill-training (Dagnan 2007).
A key emphasis in this movement is the active involvement of the person and their families in all areas of the support network, often through person-centred planning and personal outcome measures (e.g. Council on Quality and Leadership in Supports for People with Disabilities 2012).
Positive behaviour support is one example of a best-practice model of support for challenging behaviour which assumes a person-centred approach and considers both individual factors and environmental factors. Another emerging model of behaviour support is the Eidetic Model of Growth (EMG), which is an adaptation of eidetic psychotherapy for use with people with intellectual disability, in day or residential settings (Syed 2012). Eidetic psychotherapy, championed by Akhtar Ahsen (1965, 1977), emphasises the role of mental imagery in cognition and memory, particularly around emotive experiences. In this approach, mental imagery is central to therapeutic interventions that address emotional difficulties and disorders. In line with the eidetic approach, mental imagery is considered to be the primary medium of psychological functioning in EMG and is the main therapeutic target for treatment of emotional issues and challenging behaviour.
The EMG emphasises the emotional difficulties that can underlie challenging behaviour and seeks to address these through the systematic application of personal and environmental supports. In addition, social and biological factors that affect the person’s behaviour and functioning level are considered, to establish a biopsychosocial formulation of the person’s difficulties (Syed 2012).
The Eidetic Model of Growth Assessment and Intervention Process
An individual presenting with challenging behaviour is initially assessed by carer interview and observation and/or individual interview to ascertain their family and medical history, recent life events, their personal circumstances (e.g. relationships, living situation, activity preferences) and their environment. Based on this assessment, a formulation is established of the likely factors contributing to and maintaining the behaviour. This formulation then guides the person’s personalised intervention.
There are four main components to intervention, as illustrated in Figure 1. The first of these involves interventions to promote growth through ensuring that the person has access to a structured environment with choice and variety in activities, as well as opportunities to communicate about personal issues with staff. The rationale for these interventions is to increase the person’s trust and participation in their environment so as to ultimately lead to interest, creativity and growth. The second component may involve skills training in particular areas, such as training and experience in jointly resolving interpersonal difficulties or workplace difficulties among people using services. These first two components can be delivered by frontline staff under the direction of the psychologist, whereas the third and fourth components are delivered directly by the psychologist. The third component may involve interventions to remove somatic/emotional barriers to growth. This may be through the provision of individual therapy to address issues such as bereavement or anger management, or therapeutic relationship support (e.g. parent-child relationship). Individual therapy follows the principles of eidetic psychotherapy, and can be adapted for nonverbal individuals by incorporating concrete visuals (e.g. photographs, drawings). Finally, the fourth component of therapy is consultation, whereby frontline staff may be instructed or trained in supporting behaviour. The psychologist also monitors outcomes so as to measure the individual’s progress through the process of intervention. There is no ‘one-size fits all’ treatment with this model, as a person-centred approach is adopted in conceptualising each individual’s situation, with careful consideration of their environment and of their personal preferences.
Many aspects of this approach are in line with positive behaviour support, including the careful assessment of the person’s interaction with their environment and the provision of structure and staff training. What differentiates the EMG is the centrality of mental imagery and emotional factors, upon which the interventions pivot. The various components of the intervention are designed to enhance a person’s ability to visualise and to remove any barriers to growth that may have arisen through a person’s experiences. In addition, the EMG does not promote the use of consequences or reinforcement for either positive or negative behaviours.
This arises from the belief that a person’s growth as an individual is an inherently reinforcing experience that cannot be directed by other people. Instead, by systematically removing barriers to growth and providing a facilitating environment, the person is enabled to become more curious about and engaged with the world around them. This is akin to the person-centred theory of Carl Rogers which emphasised the facilitative aspects of a warm, accepting therapeutic environment (Rogers 1951).
As yet, the evidence-base for the EMG has not been established. While the theoretical underpinnings of the approach have been outlined by Syed (2012), empirical demonstration of the treatment efficacy or acceptability has not yet been produced. However, research is currently underway in the form of manualising the treatment and producing case studies and single-subject design studies as the preliminary steps to assessing the effectiveness of the intervention (Craig et al. 2008). Clinical practice in the field of intellectual disability has undergone an ‘enlightenment’ in the past few decades (Fraser 2000), and research is still catching up on these developments as the field moves towards a biopsychosocial understanding of challenging behaviour (Zaman, Holt and Boras 2007). Building evidence on interventions that take a biopsychosocial and person-centred approach towards challenging behaviour is highly important to continue to develop this field (Royal College of Psychiatrists 2007).