Challenging Behavior and Support Services A Systematic Review
This study is a systematic review on the research papers published on support services for people with learning disabilities who have challenging behavior between 1996 and 2010.
This is a comprehensive analysis that helps in developing understanding of the overall perspectives and evaluating role of social care provider (support team) in helping people with challenging behavior to get the quality of life.
The research findings indicate that the roles of social care services are very significant in helping individual with challenging behavior to attain quality of life.
Table of Content
Abstract2List of Tables and Figures4Introduction5Focus of the Review5Research Background5Research Aim and Objective10Research rationale11Research Method12Identification of studies13Study selection and data sources (Inclusion and Exclusion Criteria)14Assessment and classification of studies17Data extraction20Results22Details of included and excluded studies22Moss, Hogg and Horne (1993)29Emerson, Forrest, Cambridge and Mansell (1996)32Cullen (1999)36Vaughan, Pullen and Kelly (2000)38Emerson and Hatton (2000)41Beadle-Brown et al (2003)43McGill et al (2003)47McClean, Grey and McCracken, (2005)51Allen et al (2006)54Lovell (2008)56Mitchell and Sloper (2008)58Rose et al (2009)61McDermott et al (2010)63Discussion66Definition of Terms61Interpretation of findings72Research Limitations80Conclusion81Reference84
List of Tables and FiguresPageTable 1 PICOS of the Study16Table 2 Types of Studies18Table 3 Intervention and Definition19Table 4 Results from the Search on Different Websites20Figure 1 Selection of Paper for Systematic Review (Web of Knowledge)23Figure 2 Selection of Paper for Systematic Review (PsychoInfo)24Figure 3 Selection of Paper for Systematic Review (Social Care Online)25Figure 4 Selection of Paper for Systematic Review (PubMED)26Figure 5 Selection of Paper for Systematic Review (Google Scholar)27Figure 6 Selection of Paper for Systematic Review (Questia.com)28Figure 7 Selection of Paper for Systematic Review (University of Kent Library)29
Introduction
Focus of the Review
There have been various studies conducted in the past that has covered range of issues related to challenging behavior (i.e. Qureshi 1994 Chung et al 1996 Cullen, 1998 Emerson, 2001 Xeniditis et al, 2001 McGill et al 2003 M cLean et al, 2005 McDermott et al, 2010).
Challenging behavior is a term used to describe problematic behavior of people (Xeniditis et al, 2001). The term was introduced in North America during 1980s for learning disabilities and mental retardation. There are various terms used synonymously for challenging behavior like behavioral disturbance, problem behavior, maladaptive behavior, aberrant behavior and behavioral abnormalities (Xeniditis et al, 2001).
This study is a systematic review on the challenging behavior and role of support services. The paper is divided in four sections of introduction, research methodology, findings and analysis and conclusion.
Research Background
According to Smith and Fox (2003) challenging behavior is any repeated pattern of behavior or perception of behavior that interferes with or is at risk of interfering with optimal learning or engagement in pro-social interactions with peers and adults (p. 5).
Challenging behavior is a global term that is used to describe severe problem behavior. This problem behavior may include a variety of behaviors, including physical aggression, self injurious behavior, and property destruction. The global nature of the term has led to the problem of definition. It is not possible or sensible to search for the holy grail of an operational definition of challenging behavior which would be acceptable to all. (Cullen 1999). Emerson (2001) has defined challenging behavior as a culturally abnormal behavior of such an intensity, frequency or duration that the physical safety of the person or others is likely to seriously limit or delay access to and use of ordinary community facilities.
An individual with challenging behavior requires support and care in order to fulfill his needs and live a quality life. There are different types of support available to these individuals from family to social and private support providers. The challenge is to establish a pattern that will respond effectively to the needs of people with intellectual disabilities and challenging behavior. (Kissane Guerin 2004)
Different interpretations of challenging behavior have a major impact on prevalence figures. Chung et al (1996) found that prevalence rate in reported studies usually fall between 8 and 38 of the surveyed population of people with learning disabilities. The UK and US studies of prevalence rates of challenging behavior (Qureshi, 1994, Emerson, 2001 and Borthwick-Duffy, 1994), are the best available to date on which to base estimates for other populations (Kissane Guerin op cit). In these studies, for every 100,000 of the general population, there are between 24 and 63 people on average who had intellectual disability and serious challenging behavior.
In the context of learning disorders, challenging behavior is applied to such unacceptable and socially isolating behaviors as aggressiveness, destructiveness, self injury, regurgitation, eating the inedible, verbal abuse, tantrums, screaming, disturbed sleep, over activity, and stereotypeall of which behaviors are associated with more severe degrees of mental retardation with disproportionate frequency (Reid op cit). Although, challenging behaviors 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.
Furthermore, what behavior challenge some services clearly appear to be accepted by others. It has often been argued, for example, that the old long stay-hospitals were able to cope with much difficult behavior which then becomes an issue once the client had been transferred to the community based services. Often what happened in these large hospitals was that the person would be ignored and the stereotypy, aimless wandering, severe withdrawal, minor injuries, etc were simply not noticed (Cullen op cit).
There is no single reason which can be used to explain challenging behavior in any given scenario. Challenging behavior is usually a result of biological and psychological factors. The biological factors can be genetics disorder, endogenous substances and hormones and abnormalities in brain structure and its functioning. The psychological factors include functional perspectives, learning disabilities, personality disorder and others (Xeniditis et al, 2001).
There are four possible reasons for which an individual shows challenging behavior i.e. social attention, tangible benefits, escape and sensory. Sometimes people seek one to one social attention and in order to get social attention, they adopt different measures. Lack of communication, boredom and lack of self occupation skills may lead to such situations where people may seek attention. Tangible reasons of challenging behavior consist of direct desire of something that motivates the behavior.
In the case of challenging behavior, people adopt such practices which are troubling for others to get these desires fulfilled. Escaping is a way of avoiding attention from people. Sensory reasons includes the internally rewarding or self reinforcing activities like grinding teeth, banging head and others which may appear negative to others but positive for the individuals adopting it (Addison, 2008). Beadle- Brown et al., (2003) examined the effect of functional grouping on care practices in small group homes in England. No significant differences were found for people who were non-verbal, non-ambulant, had severe social impairment or who were verbal and relatively able. While, significant differences were found for people with challenging behavior. It was also noticed that group settings achieved less good results. Beside this, some studies also observed that the factors like learning and environmental factors, are contributing to the challenging behavior other than just psychiatric problems.
Three concepts regarding the relationship between challenging behavior and psychiatric illness are suggested by (Hillery, 1999) are primary, secondary and consequential
Primary is where the behavior is as a direct result of the psychiatric illness, e.g. one may uses aggression in response to hearing voices.
Secondary is where a behavioral response to a symptom of the illness creates challenging behavior, e.g. one may screams in response to a visual hallucination which commands a negative response from other his career and first one then uses aggression against the other.
Consequential is where the behavior begins as in primary but is reinforced by others and then becomes learned behavior, e.g. one had become aggressive as part of his psychiatric problems, and had noticed that he got a lot more attention when he did so. Despite the medication helping his psychiatric illness, he continued to use aggression as a way of attracting the attention he needed from others.
Langridge (2007) stated that difficulties with determining if challenging behavior is due to mental health problems or learned behavior can result in the inappropriate prescribing of psychotropic medication. Some of the difficulties which may arise include many and severe side effects, some of which are irreversible, some medications may have an opposite effect and actually increase or intensify challenging behavior, unnecessary long term use as the effects for cares makes them more desirable to administer, decreased participation in community and other activities due to sedating effects of drugs, suppression of adaptive behaviors and limited evidence to support the effectiveness of psychotropic drugs for the treatment of challenging behaviors in people with a learning disability.
All said challenging behavior, no matter how one looks at it, poses enormous challenge to virtually all societies and it is these challenges that services seek to address. The extent, to which services available to persons with disabilities have been able to ameliorate their conditions with a view to enhancing their quality of life, thus forms the basis of this review.
Research Aim and Objective
The systematic review in this study is aimed at studying the challenging behavior and role of support services. Provision of services for people with challenging behavior has attracted the attention of a plethora of scholars. In this study, researcher would review selected studies with a view to ascertaining the adequacy, efficiency and effectiveness of support services towards improving the quality of life of persons with challenging behavior.
The research questions for this study are as follows
Are the quality of life individuals with challenging behavior enhanced by support services
Do specialist support services address the needs of people with challenging behavior
Research aim
Research aim is to understand the impact of the support services in the quality of life of individuals with challenging behavior.
Research Objectives
Research objectives are as follows
To understand the effectiveness of specialist challenging behavior support services on individuals with challenging behavior.
To determine the role of support services in order to improve the quality of life of person with challenging behavior.
To establish the relationship between quality of life and the role of support services for the individuals with challenging behavior.
Research rationale
There have been number of studies in the past to determine the role of support services in different aspects of the lives of people with challenging behavior. This study has utilized the previous researches and findings to establish the relationship between the quality of life and role of support services. This would help in developing an understanding of the role of support services in different aspects life of individuals with challenging behavior.
Research MethodStudy selection and data sourcesAssessment and classification of studiesData extractionData presentation
Research Method
Health care decisions should be updated by the most excellent research data in order to get benefit of the most recent developments. This is one of the reasons researchers are encouraged to make use of the latest information about the health decision. There is difference between the individual studies. This inequality may be due to the difference in the way the studies were planned and performed. In this situation, it is very important to understand that which study is trustworthy and which should be used for the decision-making (CRD, 2008).
The aim of systematic reviews is to discover, assess and go over the main points of all the studies of individual, make the relevant data for policy makers. Systematic reviews are based on open, pre-identified and reproducing methods.
Systematic review is conducted on the basis of certain guidelines. These help individuals to experience and get more value out of the systematic reviews.
The Campbell collaboration website consists of the Campbell library of systematic reviews giving the full information about the systematic reviews in education, crime and justice, social welfare. The Evidence for Policy and Practice Information Centre (EPPI) presents systematic reviews involved in education, health promotion, social care and public health care.
A good review is based on the use of proper methods. Health care professional and patient representative are using systematic review differently. Some Funding bodies support the procedure and other stakeholders like, clinical experts, patient groups and service users are consulted. Reviews require modifications at the initial stages. These can be in the forms of expert opinions of the experts. According to CRD (2008) once the modifications are completed, suggestions about the reviews and the workload should accessed carefully.
Study selection and data sources
The research is based on the systematic review of the existing literature. This is a qualitative study based on secondary data. The secondary data is available in different research resources in the form of articles, journals and other research publications. The desk research has been conducted using certain keywords like disability, support services, challenge behavior, quality of life and others. These have helped in researching information from various sources. Once the articles are indentified, researcher has classified and analyzed articles on the basic of its relevance to the topic, research questions and research objectives.
The three pronged approach used to identify studies for this review are as follow
Step one
Electronic searches would be conducted using key terms like challenging behavior, intellectual disabilities, learning disabilities, support services quality of life for disable people among others would be used on academic databases like Web of Science, Social care online, Google scholar and Questia.com.
Step Two
At the second step, various journals like Journal of Applied Research in Intellectual Disabilities, American Journal on Mental Retardation and British Journal of Learning Disabilities and others would be looked at.
Step Three
The third step consists of a follow-up of references in relevant publication.
These studies would be classified and coded according to country, instruments, settings number of participants, results and research design.
In addition, the methodological adequacy of studies to be included in the study would be viewed against the backdrop of the standard classification scheme developed by Khan et al, (2001). Also data used in the studies included would be extracted, classified and synthesized through meta-analysis.
The inclusion criteria for the review are
Language of the published paper should be English.
All the paper used for the research must have qualitativequantitative or mixed methodology.
Paper is based on challenging behavior, support services or quality of life of people with challenging behavior.
Paper must be based on the population of resident with challenging behavior
The date of publication should be after 1992.
Papers must have evaluation on challenging behavior, social care services and quality of life (one ore more factors). Table 1 PICOS of the Study
PopulationIndividuals with challenging behavior
Support individuals and teams working for people with challenging behaviorInterventionSupport services for people with challenging behaviorComparatorsQuality of life of people with challenging behavior on any one or more than one variable of Social inclusion, Physical well-being, Interpersonal relations, Material well-being, Emotional well-being, Self-determination and Personal development and individual rightIntervention Support services for people with challenging behaviorOutcomesChange in quality of life of individual with challenging behaviorStudy designAny type
Assessment and classification of studies
Khan et al (2001) have provided a standard qualification for research methodologies at Centre for Reviews and Dissemination (CRD) at the University of York.
Table 2 Types of Studies
Level Description 1 Experimental studiesA study in which some conditions, particularly decisions concerning the allocation of participants to different intervention groups, are under the control of the investigator 2 Quasi-experimental studies A study in which the allocation of participants to different intervention groups is controlled by the investigator but the method falls short of genuine randomization and allocation concealment 3 Controlled observational studies A study in which natural variation in interventions among study participants is investigated to explore the effect of the interventions on outcomes 3a Cohort studies Comparison of outcomes between participants who have received an intervention and a group that has not 3b Case control studies Comparison of interventions between participants with the outcome (cases) and those without the outcome (controls) 4 Observational studies without control groups Cross-sectional studies - examination of the relationship between outcomes and other variables of interest as they exist in a defined population at one particular time before-and-after studies - comparison of findings in study participants before and after an intervention case series - description of a number of cases of an intervention and outcome (without comparison with a control group) 5 Expert opinion Based on e.g. desk research or consensus Source Khan et al (2001 as cited in Mansell, 2009)
The challenging behavior is a broad term that covers range of behavioral problems. According to Challenging Behavior Policy of NHS (2008) these behavioral problems in challenging behavior are
Physical Aggression
Verbal Aggression
Self-Injury
Property Destruction
Non- Compliance
Anti-Social behavior
There is no definition for support services available to the people with challenging behavior. The reason can be versatility of measures adopted according to the uniqueness of cases. However, there are three different intervention techniques used by the social services primary prevention, secondary preventions and reactive intervention. These three interventions are described in NHS Policy in the following ways
Table 3 Intervention and Definition
Intervention DefinitionPrimary Intervention It is defined as those interventions designed to reduce the probability of challenging behavior occurring in the first instance. Primary prevention interventions normally take place at times when there is no sign of the challenging behavior being exhibited. (NHS Policy)Secondary InterventionInvolves recognizing the early stages of a behavioral sequence that is likely to result in challenging behavior and employing a range of strategies which must be prescribed in a service users care plan to defuse and de-escalate the cycle. Secondary prevention is used when primary prevention fails and a service user begins to exhibit signs indicating that the challenging behavior may be about to take place.Reactive InterventionWhere primary and secondary prevention is ineffective, it is sometimes necessary to use reactive interventions, including restrictive physical interventions. Wherever possible these must be detailed in the service users care plan and may be informed by advance requests.
Data extraction
This review is based on the studies identified from eight academic and professional databases. These are Web of knowledge, Psyc INFO, Social care online, Pub MED, Google Scholar, Questia.com, NHS online and University of Kent Library. Researcher has used combination of key words relevant to the study for individual databases.
Table 4 Results from the Search on Different Websites
Sources Challenging
Behavior Challenging Behavior, Quality of life, support serviceChallenging Behavior and Quality of lifeSupport service and Challenging BehaviorWeb of knowledge 71n. an. an.aPsycoInfo495132202211Social care online10971271103Pub MED410117174271Google Scholar (All)794,0002730003930004600 Google Scholar (2007 and afterwards)22000160001760015500Questia.com (journals)15851481 63936607NHS onlinen.a4n.a963University of Kent Library382184207299
The list of search terms is as followed
Challenging Behavior
Quality of Life
Support Service
Challenging Behavior, Quality of life, support service
Challenging Behavior and Quality of life
Challenging Behavior and Support service
The citation searches were conducted in order to get more information for the studies that could be used for the purpose of this research.
ResultsDetails of included and excluded studiesMoss, Hogg and Horne (1993)Emerson, Forrest, Cambridge and Mansell (1996)Cullen (1999)Vaughan, Pullen and Kelly (2000)Emerson and Hatton (2000)Beadle-Brown et al (2003)McGill et al (2003)McClean, Grey and McCracken, (2005)Allen et al (2006)Lovell (2008)Mitchell and Sloper (2008)Rose et al (2009)McDermott et al (2010)
Results
The results of the search with different search terms on different databases are presented in the figures from Figure 1-8.
Moss, Hogg and Horne (1993)
Description of the Study
This study was undertaken by Moss, Hogg and Home in 1993. This was published in Mental Handicap Research. The study was focused on Metropolitan Borough. Findings of the study reveal that older people with intellectual disability were relatively high in functioning.
Findings
Main findings of the Research
Abilities of self care skills and skill for use of toilet and dressing were the common concern among the people. The highest level of performance has been achieved in modal value with the intervention of support among the two groups. In this study, people with challenging behavior who attained high scores were more likely to live in the community.
Result
The results of the study indicated that the people with learning disability (LD) of fifty years or above the age were receiving quality services. There was no reduction in the quality of services. The services available to the older people were different in philosophy and resources.
This study was based on a demographic survey of a single Metropolitan Borough. The sample size was 122 people with age fifty or above. The population included people with moderate, severe and profound disability. The sample with contact with Community Mental Handicap Team (CMHT) was 75 followed by 25 identified through an outreach study. In terms of competence, both the groups exerted similar competence, the service provisions were in individual program plans, educational opportunities and community leisure experiences. The provisions included in the study covered all forms i.e. individual Programme Plans, educational opportunities, and community leisure experiences, the CMHT group received a significantly greater input. The younger group of people with age of CMHT (51 years to 85 years) demonstrated more challenging behavior than the outreach peers (56 to 90 years).The findings supported the concern of Wolfensbergers (1985) for the appropriateness for those with LD of generic services for elderly people.
The source of contacting the target population was the support service teams in this study. The study covered all forms of individual Programme Plans, educational opportunities, and community leisure experiences.
Conclusion
The study concluded that in order to insure no significant difference in the generic services provided to the people with LD with age group of fifty and above based in differing philosophy and resourcing services, it will require caution and careful monitoring. The population studied was found to have improved their quality of life with the support of support services in meeting their daily needs.
Emerson, Forrest, Cambridge and Mansell (1996)
Description of the Study
A survey was started regarding community support teams for people with learning disabilities and challenging behavior in England and Wales. It is assessed that these kinds of teams latest employ over four fifty staff, have successively costs in intemperance of ten million per annum and provide over two thousand people with learning disabilities and challenging behaviors. Approximately one in six people with learning disabilities busy in behaviors that shows an important challenge to their carets (Kiernan Qureshi, 1993). Aggression, self-harm, over activity, spoil the environment of other person, constant shouting, socially unacceptable mannerisms and acts are included in these challenging behaviors. These kinds of behaviors are the reasons of stress in the families and frequently play an important role for decision making in the families to take residential care for their children. People who engaged in challenging behavior are frequently ignored themselves.
Over the previous decade the usefulness and adequacy of traditional approaches to helping people with challenging behavior have been called into question. Questionable long-term usefulness on the number of count up has been criticized by institutionally based estimation and treatment units. These treatment units also criticized the disturbance of relationships that result from admittance to geographically remote facilities and questionable logic of measuring and reply to challenging behavior in non-natural environments (Blunden Allen, 1987 Newman Emerson, 1991).
The numbers of locally based specialized roving teams have been established in lots of areas to support and help the people with challenging behaviors in their normal living, learning and working environments (Allen et al, 1991 Allen Lowe, 1995 Bromley Emerson, 1993 Emerson et al 1993 Lowe et al, 1993 in press, Lowe Felce, 1994 McBrien, 1994 Scorer et al 1993 Toogood et al, 1994). In October 1993, the survey was performed of community support teams for people with challenging behavior in England and Wales. This was accepted as a wider project to estimate in detail the excellence and costs of services that are provided by two such teams (Forrest et al, 1995).
The survey was started in two parts. One is on telephone that was developed with all health authorities, NHS trusts and supplier units and local Authority Social Services Departments involved in buying or giving learning disability services in England and Wales to recognize existing community support teams. This guided to the recognition of sixty five operational teams. Second is a postal questionnaire was circulated to all sixty five teams in October 1993. Forty six teams were given the usable reply that means 71. This postal questionnaire include the following such as, a depiction of services provided, management of funds, medical appointment and eating procedures, estimation methods employed, management of case load, philosophy and orientation, arrangements for working, staffing and reported results. On the reliability and validity of questionnaire, information is not available.
Findings
The community support teams are the latest and modern phenomenon. For more than five years only three of the teams replying to the survey had been operational. In fact, 26 or 54 of respondents had been operational for three years or less than three years. So the survey was practiced in such area in which there is a process of evaluation.
Main findings of the Research
The rapid and significant resources are invested in community support team approach. Information related to the annual revenue expenditure directly linked with the team staffing and normal running cost that available for thirty eight teams. The average expenses linked with these teams was 154,000 per annum. Nine services are included in voluntary sector on their routing groups while, only three are included in parents and career representatives. Revolving arrangements for leading routing group meetings were activated in five teams. The routing groups who accepted the responsibilities could be divided in those linked with accountability to suppliers, managing agencies and those related with the operation and functions of the team. The former included the policy development, reconsidering performance and funding, planning of service and assurance of quality. The responsibility of operation included the following such as medical appointment and eating, workload and caseload planning and solves the problems. In October 1993, four hundred sixty staffs were recruited by the community support teams in England and Wales. A number of teams recruited personnel who did not have professional qualifications. Seventeen teams recruited a total of twenty nine support employees who give practical support either in estimation or implementation of programmes.
Result
The result of this survey is that around fourteen hundred people with challenging behavior have been served successfully by community support teams and rest 850 people were not served by this support team. The community support team was unsuccessful for 850 people with challenging behavior. Many teams commonly focused on giving technical support or giving some professional advices related to careers and help to support staff, providing services to the adults, emphasizing pro-active work rather than crisis management. These support teams are managed and funded and staffed by NHS provider agencies.
Conclusion
The capacity and quality of the mainstream services for people with learning disability depends on team operating procedures, effective management of consultancy process and skilled performance in the assessment and treatment of challenging behaviors. According to the researcher, ignoring any of these aspects would lead to compromising sustainable and significant outcomes.
Cullen (1999)
Description of the study
This is a review of certain important issues in Research and Services for People with Learning Disabilities and Challenging Behavior by Cullen. This paper was published and prepared for the Social Work Service Inspectorate of the Scottish Office (Home Department. The paper provided reviews of the services to the people with challenging behavior.
Findings
The results of this review stressed on this fact that it is important to understand behavioral function in order to address the problem of challenging behavior in long term. The support, medication and treatment depend on these factors. There has been different literary work mentioned in the study that covered the attitudinal and perception aspects of the staff in dealing with challenging behavior. The study emphasized on looking from the person with challenging behavior, understanding the reasons of challenging behavior, try to understand the optional behavior that could take, developing interventions according to the results of analysis and assessment of the subject. Psychotherapy, cognitive behavioral approaches and behavior analysis can be used for this study.
Comparability
This review covered various aspects of the challenging behavior, social care, intervention, treatments, medication and needed approach for the study. The
Result
The findings of the study were based on various studies conducted for the social care and different aspects of challenging behavior. The study particularly focused on the staff and their role in providing services to the people with challenging behavior. Following are the important issues resulted in this study
Procedures such as seclusion and time-out as well as various forms of punishment, should be avoided
Constructional approaches are those which address the behavior
Constructional approaches put the emphasis on staff reaction to the challenging behavior, rather than the behavior itself, hence my personal preference for the term interactional challenge
Strength and Weakness
The study was based on the secondary analysis of the previously conducted study. This was drawback which could be compensated by the fact that report was part of a large report prepared for the government organization. The studies used in this review are from the authenticate sources and reliable. This supports the reliability of the paper.
Conclusion
The study indicates that there are various factors that impact the social care services to the people with challenging behavior. The sources of challenging behavior are different and treatment requirements are different. In general, treatment of challenging behavior is a long term process. However there is need of understanding the concept, relevance of the impact of different environmental factors to the people with challenging behavior, feedback mechanism, training and control for the staff and others.
Vaughan, Pullen and Kelly (2000)
Description of the Study
This study is based on the Community teams in Wessex. They are dealing with the mentally disordered offenders (MDOs) in the community. Four out of five members of the Wessex Consortium, Hampshire Social Services and Hampshire Probation Service were included in the study. Interview along with explanatory letter were left for the respondents. The proficiency schedule was designed. This aimed at measuring ability of the members in twelve key areas of work of MDOs. The scale of proficiency has four parameters of nil, weak, competent and strong. Nil or weak responses indicated that there is a need of training whereas strong responses indicated the proficiency. According to Vaughan et al (2000), Mentally disordered offenders were defined as people with challenging behavior.
Findings
For the research a total of 91 community teams were identified and 85 team leaders and managers were interviewed with the response rate of 93. There were 346 key workers who participated in the study. These supported total of 9915 clients. Out of these 8 (774) were mentally disordered offender. The offenses or challenging behavior included nuisance, public disturbance, burglary, theft, property damage, arson, sexual offences, domestic violence, violence to staff, violence to others including homicide, self harm and suicide risk and others. Client could have one or more than one type of challenging behavior.
Main findings of the Research
In the mental health teams MDOs proportion of case load was 7, learning disability teams it was 13, drug and alcohol teams it was 3 and probation teams are 7.5. Primary diagnosis of Mental health teams are most commonly a psychotic illness, above 25 learning disability teams had psychotic illness and personality disorder, 25 have a psychotic illness (schizophrenia), 25 have a personality disorder and have depressionanxiety. One-third of the probation teams have personality disorder psychiatric conditions including one fifth with learning disabilities. Offences and challenging behavior in mental health teams had high levels of violence, public disturbance and self harm and suicidal, learning disability teams had very high levels of violence, sexual offending (35), property damage and self harm, 33 of the drug mostly a low level of offences but a significant amount of self-harmsuicidal behavior and 15 violence, acquisitive offences and sexual offences in the alcohol teams and probation teams. The service shortfalls have been identified in the areas of day care occupation and accommodation issues in all of the mental health teams, learning disability teams, drug and alcohol teams and probation teams. The mental health servicestherapies and counseling were the shortfall areas of the probation team.
Result
The study reveals that most community services were not organized. The result of lack of facilities contact with MDOs tends to shun services. The teams with specific client group oprate within the same only. There is no flexibility in terms of work with other client groups. This is limiting the abilities of meeting needs of each group in cohort of MDOs. The restriction of nature of the services makes it challenging to have wider range of skills. The highest rates of violent, self destructive and sexual offending behavior exist among the groups of learning disability supporting teams. Learning disability teams have much of case loads. This restricts them to spare time for reporting competencies in working in the areas of mental illness, personality disorder and offending behavior including sexual offences. The training need for probation officer is needed in all aspects of the clinical, organizational and policy aspects of mental health.
Conclusion
The study was concluded with the statement that support, education and co-working can be provided by the forensics care team and provides link between secure forensics services and mainstream psychiatry.
Emerson and Hatton (2000)
Description
This is a qualitative study on the violence against social care workers. This is one of the areas that have received lower number of researchers. The social care workers dealing with people with challenge behavior has threat of physical risks, violence and serious physical risk on the routine basis. This is a review on the best available information on various violence incidents in Care setting for people with problem behavior. This is a qualitative study that allows getting a perspective of the violence and challenges faced by people of social care. The paper covered the aggression, violence and problem behavior of people with learning disability.
Findings
Nearly 7-10 of the people with learning difficulties are reported to be engaged in violent behavior to their service providers. The forms of aggression includes punching, slapping, pushing or pulling (51 of people showing aggression) kicking (24) pinching (21) scratching (20) pulling hair (13) biting (13) head-butting (7) using weapons (7) choking, throttling (4) as reported by Harris (1993) in the study involving 168 people with learning difficulties. Serious management problem was a major source of aggression. Abuse, inappropriate treatment, wrong diagnosis is some of the major problems. Inappropriate treatment of people with challenging behavior was evident from wrong prescription of neuroleptic (ant-psychotic) medication in two cases, wrong diagnosis of challenging behavior as psychiatric illness, prevalence of prescribing of neuroleptics, and other wrong medications had side effects and further implications. Exclusion, Deprivation and Systematic Neglect are some other reasons of violent and challenging behavior.
Result
The results of the study helped in identifying various reasons, practices adopted and implications of the same on the people with challenging behavior and learning disability and the need of changes in the policies in order to minimize the violent behavior on care staff. The result emphasized on identification of factors within current services that act as barriers to the implementation of positive behavioral support for staff for people with learning disabilities and challenging behavior and need of training in prevention diffusion and management of violent incidents. The second research task was to evaluate costs and systemic impact of the same.
Strength and Weakness
The research was qualitative study based on the studies of the past. The lack of primary data is one of the weaknesses of this paper. However the kind of information required and collection is a challenging task.
Beadle-Brown et al (2003)
Description of the study
This was a cross sectional study based on UK. The study was divided into three main areas of understanding. The first part was study of the resident characteristics, care practices and outcome in residential care for people with intellectual disability. This was an effort to fine out the care practices and outcomes for those who did not had challenging behavior but lived with people having challenging behavior and the social care available to those with some vulnerability like sensory impairments or non-ambulant as well as people with different level of independence. The study also focused in the number of people with challenging behavior living in the home matters. The third part of the study examined the frequency and type of challenging behavior in the research setting. In this study total participant were 303 people and lived in 68 small homes in England which was given by National Charity. Such participants were selected from the study of 495 people which was 95 of the total population of the people. On the other-side National Charity provided home which was 6.5 place (range 2-14) in that staff ratio is 0.65(range 0.3-3.1) and length of service is 44 months (range 5-104), Staff teams had widely varying compositions and training the percentage of senior staff (Manager, Deputy Manager or Senior Team Member) ranged from 31 to 100, with an average of 64. The percentage of the charitys own management development programmed completed by each Service Manager averaged 69 (range 0 to 100).
Measures
There are four measures used in this study which are as follows
For People with Challenging Behavior
ABS measures for independence and adaptive behavior has been used in this study which is divided into ten behavior domains of physical development, language development, domestic activity, numbers and time, economic activity, independent functioning, vocational activity, self-direction, responsibility and socialization. The maximum score for this is 322.
The second measure used in this study is Behavior Problem Inventory (BPI). This has 29 specified problem behaviors in group relating to self-injurious behavior, aggression and stereotyped behavior along with chances of additional problems.
Social Impairment Scale (SIS) was used for rating social impairment. This is a 7 item scale that covers social impairment based on Abnormal Behavior section of the Handicaps, Behavior and Skills Schedule HBS. These covers aspects like whether the person made and used eye contact with other people, spontaneous show of affection, their response to age peers, social play, willingness to join in leisure activities and overall quality of social interaction. The score can be anything between zero to hundred where lesser the value higher are the chances of profound social impairment and vice versa.
Measurement of Care Practices
Active Support Measure (ASM by Mansell and Elliott, 1996) was used to study quality and nature of the staff. This 15 item scale consists of these factors age-appropriateness of activities and materials, Real rather than pretend or very simple activities, Choice of activities, Demands presented carefully, Tasks appropriately analyzed to facilitate client involvement, Sufficient staff contact for clients, Graded assistance to ensure client success, Speech matches developmental level of client, Interpersonal warmth, Differential reinforcement of adaptive behavior, Staff notice and respond to client communication, Staff manage serious challenging behavior well, Staff work as a coordinated team to support clients, Teaching embedded in everyday activities and Specific, written individual programmes in routine use.
The assessment schedules (The ABS, BPI and SIS) were sent to managers of each home to be completed by member staff. The care practices and engagement were direct observation of the researcher.
Comparability
There are different levels of comparisons going on in this study, starting from people with challenging behavior and detrimental effect on the other people, effect of people with challenging behavior on each other and relevance of frequency and type of challenging behavior.
Result
The findings of the study revealed that people with challenging behavior receive poor health care services when they live in group setting.
There was no impact on the people with any challenging behavior living with people with challenging behavior as per the Kruskal-Wallis analysis.
Mann-Whitney analyses revealed that there is hardly any difference for people living in homes without severe or potential server challenging behavior and people living in homes of less than 75 resident with challenging behavior. However there was some difference in the cases where people were living with more than 75 residents had challenging behavior.
There was no significant impact of the severe and frequent aggression.
Strength and Weakness
The ABS, BPI and HBS are the reliable and valid instruments. Pretest and posttest reliability check was conducted. Cohen Kappa was used for accessing inter rater reliability.
The findings of Beadle-Brown et al (2003) produced different results from the Raynes (1980) study where in significant negative effects on care were identified. However the data reliability and validity provides strong support to the study.
Conclusion
The study provided insight on the kind of care people would receive in different settings. This study indicates that it does not matter in the kind of service one would receive whether he is living with people with disability or not.
McGill et al (2003)
Description of the study
The objective of this study was to understand identify the setting events reported by care staff as more and less likely to be associated with the challenging behaviors of people with intellectual disabilities. This study was based on the interviews with 65 staff working with 22 individuals.
Findings
This study also helped in understanding the relationship with the particular setting like crowded room. This is associated with challenging behavior. It is reported in the study that different settings that comes under the environmental analysis have different impact on the challenging behavior of an individual. This study helped in developing the relationship between the settings and challenging behavior. This knowledge of setting and its relationship with the challenging behavior helped in identifying reasons from the supporting and working accordingly.
The use of the inventory described here, or modified versions, may be a useful way of identifying relationships between setting events and challenging behaviors. The reported relationships identified in this study suggest ways in which routine service provision might be modified to help prevent challenging behavior.
Setting events associated with moreless likelihood of challenging behavior. It is clear from the findings of the paper that the setting events and challenging behavior are related with each other. Sometimes these have been found as primary sources of motivation for the challenging behavior.
The main findings of the research are
Staff reports indicated a number of different relationships between setting events and challenging behavior. Some events were reported to be strongly associated with the occurrence of challenging behavior, some with its absence. Some were reported to be inert, others to be idiosyncratically associated with occurrence, absence or inertness.
The results suggested that different categories of setting events contributed different relative amounts to variation in reported challenging behavior. These findings will be discussed in turn
Comparability
Data collection process consists of collecting data from eighteen residential service settings. These are provided by a variety of different agencies. The settings usually have the following parameters
Size having on average 10 clients (range 2-27) and 14 staff
(Range 5-26).
Parts of larger units (e.g., a bungalow in a village community) or completely independent of other services
Data were gathered on 22 people with intellectual disabilities. Thirteen out of these were male and nine were female. The average age of participants was 30 years (range 13-54). As described by manager the intellectual disability was mild in 4 cases, moderate in 5 cases, severe in 11 cases and profound in 2 cases. Sixteen participants had additional disabilities i.e. epilepsy, hearing impairment, physical disability, social impairment, psychiatric disorder or significant chronic illness.
Three were in no speech whereas nineteen used at least minimal spoken communication.
Following their completion of the Behavior Problems Inventory (Rojahn, 1992, updated
January 1994) residential home managers identified the most frequently occurring challenging behavior displayed by each participant. Target behaviors included aggressivedestructive (12 participants, e.g., grabbing staff clothing), stereotyped (6 participants, e.g., holding hands in front of eyes), self-injurious (3 participants, e.g., hitting head against objects) and other difficult (1 participant, refusing to eat) behaviors. Managers were then asked to identify the members of staff in whose presence the behavior was most likely and least likely and one further member of staff whose presence made no difference.
Result
The Ecological Interview (EI) was used to interview the respondents. This was based on a schedule constructed by the authors (drawing on Wahler Cormier, 1970). The familiarity of the respondents and the participants has been identified in advance and the challenging behavior and its definition was agreed upon.
There are different types of responses collected from the respondents such as their experience of the frequency, duration and intensity of the behavior. This was followed by the main part of the interview wherein they were asked about the state such as
Whether the target behavior was more or less likely (or makes no difference, or not
applicable) across a range of setting events organized into categories as follows physical setting (12 items, e.g., living room) time of day (9 items, e.g., first thing) day of week (7 items, e.g., Monday) time of year (6 items, e.g., at Christmas time) weather conditions (6 items, e.g., stormy) activities (13 items, e.g., eating or drinking) the presence of particular clients (number of items equivalent to number of other clients in setting) the presence of particular staff (number of items equivalent to number of staff in setting) social context (9 items, e.g., alone) personal context (14 items, e.g., when he or she is ill).
The categories were defined with respect to the relevance of the persons setting and the level of association of the person with particular item. These categories represents from the immediate setting of the respondents.
Strength and Weakness
This study was a comprehensive approach where in different perspectives were covered within a specified surroundings. The study could not be generalized as for that more responses needs to be collected.
Conclusion
The settings of the individual have impact on his behavior. This is an important aspect to study this helped in understanding the situations of physical and social environment that can encourage the challenging behaviors.
McClean, Grey and McCracken, (2005)
Description of the Study
This study provides description of the implementation of Positive Behavior Support for five people very challenging behavior over eight month period. The outcomes were presented as rates of behavior, rates of medication, psychiatric symptomatology and quality of life.
All five were on the National Intellectual Disability Database and presented with challenging behaviors which were rated as 5 on the Harris severity scale, defined as behaviors that caused very serious tissue damage to other personself (e.g. bones broken, deep lacerationswounds). Hospitalizations andor certified absences from work necessary during the past month.
On-call intensive support services, emergency respite care, mental health review and behavior support planning was included in systems of support.
Support systems identified in the study was behavior support planning meetings, mental health reviews, intensive support workers, emergency respite care and crisis response.
Findings
After implementation of Positive Behavioral Supports, the behavior reduced to near zero levels and it was sustained during the 18 month duration of the study. The medication requirements in this period were reduced by 66. The Quality of life scores improved significantly among the three participants out the total five. The revenue costs of the service have also been calculated for the period of 18 months. This was based on the cost of the staff allocated to a day or residential service and calculating the days the person availed of the service and calculating the additional cost of frontline staff allocated to the individual.
Main findings of the Research
The implementation of positive behavior support plan is directly linked with substantial reductions in challenging behavior among all the five individuals. This plan is multi element. The community based model with four elements is the base for the multivariate research. The comprehensive model of assessment and intervention reveals that five individuals studied needed a multi-element behavior support plan and frequent reviews on the medication needs. There has been intensive study for psychology, psychiatry and social themes for understanding all the five individuals. Individually cost continuum of care reveals that it is important to have a flexible financial structure in service for people with challenging behavior.
Conclusion
Staff support for community living reveals that the service has enhanced the well being and quality of life of the participants. Individualized staffing for supported employment supported living and supported leisure activities. Place of safety during times of crisis was the other aspect studied in this study. This illustrates that people with severe challenging behaviors can maintain their place in the community of live with adequate support. Service options include acute psychiatric treatment in mainstream psychiatric hospital, small community based respite facilities, individualized residential and day services, high support homes in the community and on-call intensive support service.
The study was long intervention based study however relatively small sample size. This makes it difficult to generalize the outcomes.
Allen et al (2005)
Description of the Study
This study is based on the Special Projects Team (SPT). SPT is one of the major initiatives for people with challenging behavior in the UK. The study was established in the context of increasing knowledge of the effective treatment responses within the lack of widespread expertise as well as growing crisis within challenging behavior services. The outline of multi component, comprehensive and tiered support system, project brief and principal objectives, key activities like resettlement, epidemiological and service mapping study, training courses and development of courses, networking with other organizations. This is indicated in the study that various studies have shown that challenging behaviors are common among people with intellectual disabilities.
Findings
Review was conducted for SPT and its performance. SPT ahs four principle objectives
To co-ordinate and further develop existing specialist tertiary services for challenging behavior
To develop a range of state-of-the-art demonstration projects at primary and secondary service levels, in conjunction with partner agencies
To improve significantly front-line knowledge and competence in supporting people who challenge via the widespread dissemination of training and good practice at primary and secondary care levels, and
To evaluate the impact of interventions and generally improve the knowledge base concerning people with intellectual disabilities and challenging behavior
Main findings of the Research
The permanent establishment consists of seven senior staff with clinical practice, social residential care, nursing, psychology, forensic services, management, training and research two psychology assistants and an administrator backgrounds.
The key activities included resettlement that includes the impact on quality of life of the service user, comfortable, safe and equipped buildings with staff for the people with challenging behavior. Service mapping to deal with the accurate strategic planning of services and deal with the lack of knowledge. Staff training is the third major area of the study. The development is reported to be accredited and evidence based. The positive behavior support for staff is available at primary, secondary and tertiary levels.
The research reviews on the relevant topic by team is ongoing process and the involvement of the team in smaller scale studies has been encouraged with the conjunction of Challenging Behavior Foundation. One more partnership with Autism Cymru that focuses on the experience of people with Asperger Syndrome is about to start.
Conclusion
The study indicates that the formation of SPT was able to achieve its initial milestones. This is the reason for broadening attention to work with more partner agencies. This initiative not only trains and develops the staff for working with people with challenging behavior but also supports them in keeping themselves updated and informed. Training materials are designed taking care of all the efficient and effective way of progressing.
Lovell (2008)
Description of the study
This study based on critical study of different data collecting methods, direct observation and semi-structure interviews with parents and with professionals. The data collection comprised of the archive materials like clinical case notes, professional reports and personal correspondent. All the chronological case record and life history account as well as used various resources of investigation specially the use of human document which helps in giving all accounts and background study. Even some of the studies also based on peoples life stories and in this article Lovell had lighted on six stories out of fifteen.
Findings
People with severe learning disabilities appear less likely to be afforded such respect and their actions regarded with incredulity and less rationally. However this study argues that self injury is rational and our limited understanding of learning disability limits us to learn. The function approach of self injury results in the development of an impressive behavioral armory. This provides opportunity for interdisciplinary cooperation. It can be response to traumatic life incidences or history like sexual or physical abuse, violence, exposure to alcoholism. Emotional overload may result to anger and anxiety which can be reasonably justified.
Comparability
The reports used for the study of this paper were reports prepared by the social work standard assessment, interview with staff nurse, behavioral support team care plan, GP correspondence to social worker, social service progress review, social work standard assessment and others were prepared and complied by various social care service provides. The focus of the study was on one of the aspect of challenging behavior that is self injury. The reason for the same can be disability to incidence from life history.
Conclusion
Self injury is a challenging behavior with dependable mechanism for dealing with everything from contentment with life. It is constant across time and space.
Mitchell and Sloper (2008)
Description of the Study
The study is based on the Integrated Childrens System (ICS) that is marked as important stage in the Government Policy to improve outcomes for children in need and forms part of Every Child Matters Change for Children agenda in England. The aim of this study was to support and coordinate the introduction of ICS in five local authorities of England (three) and Wales (two). This study has the perspective of service providers and users and covered various aspects of referral, assessment, planning, intervention and review. The role of ICS in developing the understanding of social work process and making more sense of happenings of their lives. The issues covered from the service providers perspectives were the additional time needed to compete records and its cost, training needs, use of technology and requirements of additional technology. This study explored the experience of parentscareers and disabled childrens experience of how information is being collected under the ICS system.
Findings
The results of the study revealed that IT training was available on request to the social work staff. It was based on the staff and their identification of their needs.
Main findings of the Research
Data was collected in the form of interviews with parents, children and social workers. The analysis of interviews with social workers and parents were done on the basis of Framework analysis which is a comprehensive mechanism of identifying over-arching themes across the transcripts. The sixteen social workers working with 22 families across four pilot authorities has been grouped into four broad themes of exploring training, technology and management issues experience of using the ICS exemplars relating to service users and carers and social work practice of general and disability specific has been considered.
The key findings reveal that there was a problem of access to personal computers for the social workers. Initial problem of system resulted in delaying the overall documentation process leading to extra work for social workers and administrators. The resource problem was identified in the study. Anomalies, inconsistencies and system crashing were some of the major problems faced by the social workers. However the social workers felt that it is very secure to have system files than the hard copy as it becomes difficult for any one without adequate permission to access to these files. Thus families can not access the information. General and particular information regarding families can be collected easily. The concerns of social workers were in duplication of the problems associated with the Framework for the Assessment of Children in Need, more guidance and free space sections, generalized and bland care information, inappropriateness of using age related exemplars, incorporating information in different formats, unrealistic timescales and training.
Result
It was stated that the ICS exemplars did not take account of the fact that parents with disabled children provide extra care over other parents. The need of change, radical rethinking was felt to acknowledge the child protection bias and developing sensitive and appropriate exemplars. The social workers stated that the ICS exemplars should meet the disabled children and their families. It was stated that the exemplars were inadequate and at times confusing. The social workers felt that it needs to be more clearly designated sections to record the issues specific to disability. The social care workers felt that the in dept and specific care needs of disabled children and caring strategies and preferences of the families should be included in the ICS exemplars. The mismatch of the chronological age and cognitive development for disabled children needs to be studied, the learning milestones should be included appropriately and positive experience should be promoted. The positive aspects of the ICS exemplars is considered as the reduction in the administrative demands on social workers working with disable children and their families, reduction in the variation of practice, specific care needs or use the same forms. The chances of getting the information on the updates by the relevant parties were easy to record.
This study covered different aspects of the ICS and its impact on the working of the social workers. There were some issues related to the adaptation of technology and information management within this system and the practical aspects that has been covered in this paper.
Conclusion
The study revealed that the ICS has some potential for being useful in serving disabled children by the social workers however there are adaptations needed in this system in order to realize its potential. The significance of ICS was identified by the social workers not parents. The face of the social working organizations were the social workers and their good social work practice was key issue for the parents.
Rose et al (2009)
Description of the study
Here study based on an evaluation of three centre-based projects established by a organization under the Scottish Governments Youth Crime Prevention Fund to work with primary school aged student who displaying challenging and antisocial behavior.
Findings
This paper provides evaluation of three centre-based projects established by a voluntary organization under the Scottish Governments Youth Crime Prevention Fund. The aim was to work with primary school aged children displaying challenging and antisocial behavior. The idea was to develop the understanding of the effective interventions and describes the projects ways of working, including their remit and ethos. The core intervention chosen was the well tested Webster-Stratton training programmed, The Incredible Years.
Result
Three sites were identified and the paths of individual children were plotted across these three sites. This helped in understanding the number of children moving to particular direction. Children were scored just before intervention and within 3 months of the end of intervention.
The results of the study revealed that the parents role in dealing the changes of behavior and providing positive behavioral changes is very important. Parents can understand the need of their child and children can associate them in better way with the parents.
What the projects demonstrated is that that even the most vulnerable children and parents can change their behavior, given the help they need, when and how they need it. The projects showed that a structured group work programme could be effective, but for families of this level of vulnerability, it needed to be supported by dedicated workers with families and by wrap around services over a sustained period. To expect the children and parents who came to the project with so many problems to turn those around in a matter of weeks would be unrealistic. What the projects did is to start the children and families along the road to change.
Conclusion
Range of measures, processes and service intervention was adopted and role of parent and family in the service intervention was studied. The parental stress has been covered in this study. The study suggested that projects had provided valuable turning points for some of the children with out-of-control behavior and their families. Finally, it is suggested that a better way to evaluate such projects could be to use complexity theory
McDermott et al (2010)
Description of the study
This study is based on the Integrated Services Project for Clients with Challenging Behavior (ISP). It was established in 2005. It is administered by Ageing, Disability and Home Care (ADHC), Department of Human Services NSW. The study was based in Australia. The aim of the study was to foster improved life outcomes for people with complex needs and challenging behaviors reduce the cost of this group to the service system and the wider community and contribute to the evidence base in this area. The Social Policy Research Centre (SPRC) was commissioned to conduct an independent evaluation of the Project in 2007
Findings
Eight people were accepted into the project in each quarterly round on the basis of the intensive level of support required by each client. The total number of clients served over this period was 38 with median age of 35 years. The guardianship orders were applicable in 89 of the cases. All clients lived in insecure housing upon entry.
Clients had a complex mix of disabilities and diagnoses, of which the most common was mental illness, followed by intellectual disability and alcohol and drug disorders. Almost all clients had a mix of two or more diagnoses.
Clients experienced a decrease in the frequency and impact of their challenging behaviors which contributed to a considerable decrease in the amount of hospital and criminal justice services used by clients. In particular, there was a 90 per cent decrease in the number of days spent as an inpatient in hospital, an 82 per cent decrease in the number of hours spent in emergency, and a 94 per cent decrease in the number of days spent in custody.
As reported by Staff and stakeholders, ISP successfully supported its target group. The project was flexible, provided consistency of support, stability of staff, and ability of the Project to learn from experience.
Recommendations
The recommendations were given at clients level in the form of suggestion for follow up, identification of the characteristics of people has ISP support and determining the predictive factors that would help the clients the most. Other client outcomes were the development of a client management system. This should capture client outcomes. It could be useful to track people over time.
There were recommendations given for the Service model and governance. The feedback to agencies as to the reasons nominations were not accepted. This would assist in maintaining and strengthening relationships with partner agencies. The other recommendation was the optimal care should be given to ensure optimally support the ongoing work of ISP. Flexibility of arrangements was one of the focus areas recommended Consideration should be given to implementing more flexible funding arrangements that can be used to support people outside of the Sydney area.
The Project has transitional model. It may not be appropriate for all clients. Therefore it was suggested that core emphasis on sourcing and supporting people in permanent accommodation from the outset may be beneficial for clients. The service system aspect was covered in the study with the following statements
The Project has the potential to play a key role in advocating for systemic change which focuses on finding sustainable solutions for people with complex needs. Such advocacy could include increasing expertise in the system about how to effectively manage this client group, promoting flexibility and sustainability of funding, and developing more appropriate community based accommodation options for people with complex needs.
The ISP should review its relationship to the NGO sector. This is particularly needed in relation to the Projects governance structures and referral processes.
Conclusion
There have been evaluations that supported the success of ISP in establishing a service model. This has led to positive outcomes for clients. The ISP is flexible to support. It can be tailored to the needs of each client. The Project can remain responsive to changing needs.
DiscussionDefinition of TermsInterpretation of findingsResearch Limitations
Discussion
Definition of terms
Disability
A disability is a restriction or lack of ability to perform an activity within the range considered normal for a human being. (Roy, Roy and Clarke)
Challenging behavior
There are various definitions developed for challenging behavior by different authors and professionals. Some of these have been taken account in this study. These are as follows
According to Emerson (1993) challenging behavior is, culturally abnormal behavior of such intensity, frequency of duration, that the physical safety of the person or others is likely to be placed in jeopardy, or behavior that is likely to seriously limit or delay access to and use of ordinary community facilities.
Qureshi (1994) defined that a person will suffer from challenging behavior problem if,
i. heshe causes more than minor injuries to himselfherself or others, or destroy hisher immediate living environment. or
ii. at least weekly, Shows behavior, that required intervention by more than one member of staff to control or remove heshe from physical danger, or caused damage which could not be rectified by immediate care staff or caused at least one hours disruption. or
iii. At least daily, causes more than a few minutes disruption (Adopted in Challenging Behavior Policy by National Health Survey, US).
According to McGill (2003),
Challenging behavior is difficult or problem behaviors, which may be show by children or adults with a learning disability. Aggression ( such as hitting, kicking, and biting), destruction (such as ripping clothes, breaking windows and throwing objects), self-injury (such as head banging, self-biting and skin picking), tantrums and many other behaviors (such as running away, eating inedible objects, rocking or other stereotyped movements) may be included in these problematic or difficult behavior. Characteristically, challenging behavior puts the safety of the person or others in some jeopardy or has a significant impact on the persons or other peoples quality of life.
Thus, from these definitions it can be said that challenging behavior includes the problematic behavior like physical aggression, verbal aggression, self-injury, property destruction, non-compliance and anti-social nuisance behavior. The pattern and extent of these behaviors varies with type of behavior and age of person.
Disability
Disability is socially defined and refers to the interpretation of impairment by others (Braddock and Parish, 2002). Thus, disability is viewed in its cultural and societal context, while impairment designates a known biological condition. Davis (2000) wrote Disability is not so much ... the presence of a physical or mental impairment as it is the reception and construction of that difference.... Impairment is a physical fact, but a disability is a social construction. For example, lack of motility is impairment, but an environment without ramps turns that impairment into a disability ... a disability must be socially constructed there must be an analysis of what it means to have or lack certain functions. (Harris, 2006 p. 56)
Disability can be described in various levels. It can be partial or total or temporary or permanent. There are various factors are included in disability status of an individual. These factors can be result of particular medical conditions like general health and age, type of harm, mental or physical or both, severity of harm, physical capacity and mental capability. The international classification of functioning, disability and health provides a framework of capacity, wellness, capacity and performance with respect to the functioning and disability.
Mental capability includes knowledge tolerate stress, honesty and faithfulness and others. Social factors include the social setting of an individual, family, friends, siblings, guardian, teachers and others who jointly make the social surrounding of an individual. The cultural factors, ability to participate in cultural activities, family factors, education, financial conditions, economic dependencies and others have impact on the disability status of an individual. There are different factors that are considered before determining disability status of any patient by the professionals.
Disability, under the ADA include the physical and mental harms of the individual such as walking, seeing, hearing, learning, working, sitting, standing, etc., verification of these harms. The short-term and small harms are not included in this Act.
The Americans with Disabilities Act (ADA), which is administered and enforced by the Equal Employment Opportunity Commission, was signed into law by President George Bush in 1990. From an occupational perspective, Title I of the law prohibits discrimination against otherwise qualified individuals with disabilities by private-sector employers, state and local governments, employment agencies, labor unions and joint labor-management committees. (Barron, 2001)
According to Barron (2001) ADA prohibits discrimination with regard to any any practices, terms, conditions and privileges of employment of individuals by the employers. This covers applications, medical examinations, hiring, testing, assignments, training, evaluation, promotion, disciplinary action, layoff or recall, termination, compensation, leave and benefits to be received by an individual in his employment. The individuals are at the risk of discrimination from the recruitment to the promotion and benefits.
Intellectual Disability
People with intellectual disability may be limited not only in their cognitive and adaptive behavior skills, but also by emotional and behavioral disorders that further limit their ability to learn new skills, adapt to changing environments and develop appropriate social interaction skills. When these disorders are of a sufficient severity and intensity, they may constitute a diagnosable psychiatric disorder (Einfeld Tonge, 1996). Hence when intellectual disability is complicated by mental illness, the common clinical term dual diagnosis is used to describe these individuals (Bongiorno, 1996 Matson Sevin, 1994 Lovell Reiss, 1993). The term dual diagnosis indicating a co-existence of intellectual disability and mental illness is relatively new and has only recently been acknowledged in the field (Borthwick-Duffy, 1994 Fuller Sabatino, 1998 Parmenter, 2001 as cited by Hudson Chan, 2002)
Developmental Disability
Developmental disability is a substantial handicap in mental or physical functioning, with onset before the age of 18 and of indefinite duration. Common examples are autism, cerebral palsy, uncontrolled epilepsy, certain other neuropathies, and mental retardation. (Dorlands Medical Dictionary)
Support Services
In this context of research, support services provide care, help and support to the person suffering from challenging behavioral problem through interventions and preventions of the causes and implications.
Quality of Life
Quality of life of an individual consists of various factors like social inclusion, physical well being, interpersonal relations, material well being, emotional well being, self determination, personal development and individuals right.
Interpretation of Findings
Reinstating Challenging Behavior
Challenging behavior is a term used to describe problematic behavior of people that can put their or others safety at risk. There are various reasons of showing challenging behavior i.e. social attention, tangible benefits, escape and sensory. To get the others attention, lack of communication and self occupation skills, learning and environmental factors other than just psychiatric problems may be also responsible for the challenging behavior (McClean, Grey and McCracken, 2005).
There are various authors who argued that challenging behavior is somehow socially constructed phenomenon (Emerson, 1998 Oliver et al., 2003, Male, 2003). Oliver et al (2003) have argued over the differences of social settings and difference in the general perception of challenging behavior. Male (2003) argued that the social construction can be inferred with the interpretation of research findings. Emerson has argued that the definition of challenging behavior in a particular context depends on factors like social rules regarding appropriate behavior, ability of the person to give a plausible account for their behavior, the beliefs and perception of people regarding the nature of intellectual disabilities and causes of such behavior and the capacity of the setting to manage any disruption caused by the persons behavior. The implicit and explicit rules of a social settings and expectations of appropriate conduct govern the behavior within a social setting. This increases the complexity of the phenomenon and helps in identifying different approaches for intervention. Social and cultural factors of any social settings have significant role on the definition of an appropriate behavior and on the member of that particular setting. A socially valid intervention would be that in which the socially significant problem is covered, it is carried out such a manner that it is acceptable to the main constituencies and helps in achieving socially significant outcomes (Emerson, 2001).
There are various members of the society who provide social support to the people with disability or challenging behavior. They can be family members and siblings, neighbors and friends, community members, school staff, teachers, classmates and peers.
Challenging behavior can be result of different aspects of an individuals life that covers range of possibility of the sources like past history of abuse, disability, learning disability, social inclusion problem, lack of understanding of how to deal with particular thing and others. The settings of the individual have important role in reducing or increasing the challenging behavior. A proper assessment is needed. There are various aspects of challenging behavior covered in the study. This includes staff or service providers perspectives. The experience with each person suffering from challenging behavior is different process altogether. These staff has high risk of facing violent behavior that can lead to serious injuries.
Assessment Aspects
McLean and Grey (2005) provide range of factors that can be included in assessment like strengths, needs, history, likes and preferences, interpersonal environment, organizational settings and others. Behavior support plan should have environmental accommodation, functionally equivalent skills teaching, direct intervention and reactive strategies. The quality of behavior support plan should be defined. The structure has eight domains of quality of life are social inclusion, physical well-being, interpersonal relations, material well-being, emotional well-being, self-determination, personal development and right.
The comprehensive assessment should have factors like cognitive, communication, life story, and environmental health, psychiatric and motivational in order to find out underlying reasons for challenging behavior (McLean and Grey, 2005). The strengths can be evaluated on the basis of cognitive communicational, self help, social and leisure abilities. The need assessment starts with the impacts of disabilities, service and resource gaps in the lives of people with challenging behavior, needs for further development, mental and physical health needs. The likes, dislikes and preferences of expressions are included in the assessment. The history assessment should include the development of the individual, his social, medical and other history of using services. One of the important aspects of the assessment is the assessment of physical environment that includes assessment size, comfort, noise, access to community facilities, open spaces and safety. The interpersonal environment and organizational settings are part of assessment. The questions asked should be based on consumer driven approach asking for aspirations, relationships, home, community, work, health and safety, behavioral, social and choices. Behavior support plan should have environmental accommodation, functionally equivalent skills teaching, direct intervention and reactive strategies. Environmental accommodation includes the factors related to the factors like access to fool and drink social interactions and comfort, quality of communication and others. Functionally equivalent skills include teaching of skills for community participating, recreation and others to make the person more effective within his social set up.
Direct interventions are based on establishing rapid control over such behavior. These are based on non aversive strategies like reinforcement or reward. Reactive strategies are designed to change behavior by recognition of the proactive elements and development of supportive plans and emergency procedures.
The person with challenging behavior should get help based on the comprehensive behavioral assessment. The quality of behavior support plan should be defined. The regularity of review of any medication, the quality of the living environment and opportunity for meaningful and satisfying activity should be part of the support plan for a person with challenging behavior. The service should be evaluated the quality of individualized service planning, the protection of the person in the design, implementation and monitoring of restrictive strategies, the protection of the person who is involuntarily detained and the protection of the person who is involuntarily treated (McLean and Grey, 2005).
Social Structure and Challenging Behavior
Social structure is important for a person with challenging behavior. This can be a source of challenging behavior. Secondary social can be defined in various ways. Peer rejection and social skill deficient leads to development of problem behavior or challenging behavior among students (Farmer and Farmer, 1996). Gender and ethnic impact on social inclusion and challenging behavior has been highlighted in one of the studies.
People with challenging behavior and detrimental effect on the other people, effect of people with challenging behavior on each other and relevance of frequency and type of challenging behavior has significant role in understanding challenging behavior.
Cullen (1996) study stressed understanding behavioral function in order to address the problem of challenging behavior in long term. The support, medication and treatment depend on these factors. There has been different literary work mentioned in the study that covered the attitudinal and perception aspects of the staff in dealing with challenging behavior. The study emphasized on looking from the person with challenging behavior, understanding the reasons of challenging behavior, try to understand the optional behavior that could take, developing interventions according to the results of analysis and assessment of the subject. Psychotherapy, cognitive behavioral approaches and behavior analysis can be used for this study.
The sources of challenging behavior are different and treatment requirements are different. In general, treatment of challenging behavior is a long term process. However there is need of understanding the concept, relevance of the impact of different environmental factors to the people with challenging behavior.
Social support in many forms helps people with disability and challenging behavior (Berndt, 1989). There are various members of the society who provide social support to the people with disability or challenging behavior. They can be family members and siblings, neighbors and friends, community members, school staff, teachers, classmates and peers. The support can come from social care staffs through various levels of intervention and interaction. These help people with disability and challenging behavior to develop esteem, self respect, feeling of social inclusion, informational support in getting opinion and direction and developing the same, instrumental support like developing analytical skill and sense of belongingness (Berndt, 1989)
Resource Availability
Resource limitations have been identified as one of the barriers in providing services by the social workers to people with challenging behavior. In one case, lack of or delay of facilities was described as one of the problems for the support service providers (Vaughan et al 2000)
Training and Development
The training provides an opportunity to share the challenges faced by the staff and how to deal with the challenges, particularly the physical management skills like physical restrains. Training is an important aspect of developing skills, knowledge and confidence among the social service staff providing support services to the people having challenging behavior.
According to McGill (2003) without the opportunities of exerting such control people with learning disabilities will be in much poorer positions when they get in to situations (as they inevitably will) where they are expected to fend for themselves and speak up for themselves rather more. One of the keys to prevention (and also to treatment) is therefore to emphasize the development of communication and independence. Policymakers are also often raise concerns about the quality of care provided by these persons who may lack formal training. It was reported from two studies of Californias In-Home Support Services Program that the consumers rated family members and friends as more reliable than workers, who were strangers, (Barnes Sutherland, 1995 Benjamin, Matthias, Frank, 1998).
Winchurst et al. (1992) observed that much of the training that services provide the users is about fulfillment, from getting people to behave reasonably tobehaviormodification. This is evident that at least some of the anger and frustration underlying challengingbehavior has been provoked by the lack of control people have over their lives, we respond to that anger by reducing peoples autonomy still further. One way to try and break out of this cycle is to help people acquire the skills of asserting themselves without having to resort to aggression. Paradoxically, it is often staff that gets access to assertiveness training courses, although there are imaginative examples where such opportunities have been set up for users. The findings of the studies by Cullen (1999) Vaughan et al (2000) Beadle-Brown et al (2003) Allen et al (2005) Mitchell and Sloper (2008) and Rose et al (2009) have also indicated various needs of training among the individuals. These training needs ranged from training for interventions and different aspects of challenging behavior to the technical knowledge of using information technology. Significance of identifying training needs to the training and development has been covered in various studies.
Quilgars (2000) reported that support could encompass assistance with tasks which involved the support worker or volunteer directly undertaking that task, or enabling the person to undertake the task themselves. The goal of prevention is a worthwhile but subtle one. Because, some times challenging behavior arises also from a medical condition, a sensory impairment or similar, the more such conditions can be remedied the better. Care takers, parents and teachers can always try that the person should have what they need when they need it help, attention, food, drink, preferred activities and so on. Simultaneously, it is also very important, that people are also given the opportunities and the skills to get things for themselves or to ask for them rather than their always being available on a plate.
McGill et al (2003) provided different aspects of the settings of an individual and its impact on the challenging behavior. Different perspectives were covered within specified surroundings. People with severe learning disabilities appear less likely to be afforded such respect and their actions regarded with incredulity and less rationally. It can be response to traumatic life incidences or history like sexual or physical abuse, violence, exposure to alcoholism. Emotional overload may result to anger and anxiety which can be reasonably justified. Clients experienced a decrease in the frequency and impact of their challenging behaviors which contributed to a considerable decrease in the amount of hospital and criminal justice services used by clients. The teachers perception regarding the students with challenging behaviors in the classroom, patterns and trends, level of satisfactions or frustration in dealing with challenging behavior, support and strategies perceived to be useful for handling the challenging behavior. One study revealed that the parents role in dealing the changes of behavior and providing positive behavioral changes is very important. Range of measures, processes and service intervention was adopted and role of parent and family in the service intervention is important.
Research Limitations
One of the major limitations of this study has been the dependencies on the secondary sources of information. The research is based on systematic review. The requirements of the study are met by the secondary resources only. The time and financial constraints are the other constraints of this study. Majority of publications relevant to the study are available on the paid membership websites. This again was challenging for the researcher to complete the project within the budget. (Punch, 2005) defines delimitation as drawing boundaries of the study that clearly indicates the aspects included or excluded in the study.
This study consists of the disabilities, behavior challenges and role of support services improving quality of life. However the quality of life of a person with disability depends on numbers of factors like family, friends and their physical surroundings and environment. Therefore restricting the study to one aspect of their life is not complete it, yet is significant due to the role it can play on the individual being and quality of life of the subject.
Conclusion
Challenging behavior may be a direct result of the psychiatric illness, behavioral response to a symptom of the illness or it may begin as a direct result of psychiatric illness but reinforced by others and then becomes learned behavior. Irreversible side effect, due to opposite effect of medications, decreased participation in communication, suppression of adaptive behaviors and limited evidence to support are the difficulties in the study of challenging behavior. It is difficult to determine that challenging behaviors is due to mental health problems or learned behaviors. There are three levels of professional helps a person with challenging behavior can receive i.e. primary, secondary and consequential. Support service providers face various challenges when it comes to serve people with challenging behavior. Some academicians argued that there are no reasons for challenging behavior whereas others find that every challenging behavior has some reason or cause inducing it. Therefore this require proper assessment of different aspects of life of individual with behavioral challenge that can start with the individual, his surroundings, social relations, work relations and other aspects of life. The medical history is also important. Based on this assessment, a plan for the social care can be prepared. This plan should be evaluated against different aspects of the service receivers life after implementation. Therefore role of social service can be very important in helping individual with challenging behavior.
Support services are provided to meet the needs of people with challenging behavior and to improve quality of their life. The support networks, or governmental or related agencies provide support for their development to enable their participation in their communities. Support services are envisage to be providing assistance with tasks like moving into a tenancy, practical skills such as paying bills and budgeting, independent living skills such as cooking, domestic tasks undertaken both inside and outside the home, general emotional support, befriending and companionship, developing social link and general advice and information on services and resources within the community.
The support services are often provided to improve the quality of life of person with challenging behavior. The characteristics of quality of life vary with services, place and researcher. According to Schalock et al., (2002) in recent years, there has been a sustained attempt by researchers to develop a consensus on the concept of quality of life of people with challenging behavior. This provides an overarching structure into which different elements can fit consistently. The structure has eight domains of quality of life are social inclusion, physical well-being, interpersonal relations, material well-being, emotional well-being, self-determination, personal development and right.
Different services and different researchers in different countries have different ways of characterizing the quality of supported accommodation for disabled people. In recent years there has been a sustained attempt by researchers in intellectual disability to develop a consensus on the concept of quality of life (Schalock et al., 2002).
It can be understood by the research findings that each factor of the quality of life of people with challenging behavior needs to be expanded with the aim of developing an understanding of underlying reasons of adopting that behavioral option by the person with challenge behavior. Social service can evaluate reasons and conduct their assessments and help the person with challenging behavior to deal with this problem and get quality of life.
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