This essay intends to talk about innovative approaches to challenging behaviour in a specific Social Care Setting. The writer will discuss about approaches like counselling, the Low Arousal Approach, the Time-out Approach, Nonviolent Crisis Intervention, and many more and will then give examples using practical examples from practice placement. Challenging behaviour has being an issue on the spot light over the past years especially in young children and people with intellectual disabilities. This essay will also bring some issues that causes or promote challenging and aggressive behaviour in the social care setting.
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The term challenging behaviour was adopted from The Association for Persons with Severe Handicaps (TASH), and emphasises that behaviours represent challenges to services, rather than problems which are solely intrinsic to the individuals with learning disabilities. Emerson, et al (1987) suggests the following as a definition of severely challenging behaviour “Severely challenging behaviour refers to behaviour of such an intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to seriously limit or delay access to and use of ordinary community facilities” (Emerson, Barrett, Bell, Cummings, McCool, Toogood, & Mansell 1987; cited NSH Evidence, 2011).
There is a great concern for how people with challenging behaviour view themselves – the issues of self – esteem and self view. Work on communication and relationship goes hand-in-hand with these issues and is likely to contribute mightily to a person’s self worth if he/she is having regular positive valuing experiences in interactions with others. This is an area which might require great thought and professionalism. However, it can be very difficult to be with and generally displays negative or abusive behaviour towards others. There is no doubt that these positive experiences are necessary and likely to increase people’s sense of feeling good about themselves, resulting in positive effects in their behaviour (Hewett 1998:7).
Different people’s state of normal arousal may be at different levels; indeed some people with challenging behaviours may have a level of arousal which is normally very high. Many people with learning difficulties may experience, due to their difficulties with understanding what is going on around them. The trigger is the event occurring either within the environment or within the person which activates the state where the person’s behaviour becomes challenging (Hewett 1998:154). For example, during my placement I was able to observe this arousal in the service users I worked with and what the social care worker staffs did in situations like that.
We have a male service user in the house who suffers from Bipolar Mood Disorder (BMD), this means that sometimes he feels ”high” and sometimes ”low” which is controlled by daily medication. The following are signs that show when he is becoming unstable: burping, smoking, eating more than usual, talking excessively without waiting for reply (pressure of speech) sleeping badly, general bad mood, and giving out or teasing other service users. When he is unwell, he wakes up at the middle of the night because he gets mixed up between day and night. At this point there is always a wake up night staff with him when the service user is feeling high. According to Hewett (1998:164) the first indications of triggering in a person should lead to staff surveillance and vigilance – this should be the start of ‘tuning-in’. Members of the staff need to start monitoring the person for the signs and signals that the person’s feelings and behaviour are starting to escalate.
When the staffs working with the service user notice that the service user’s behaviour is becoming unstable as explained above and the service user is presenting with a challenging behaviour to the staff and other service user in the house, the staffs will try to de-escalate the situation because the service user in question will be verbally abusing (teasing) other service user which will make the other service user to be upset and the service user will continue to talk excessively without waiting for response and their will be pressure in the service user’s tone. In this case, the staffs will bring these to the social care leader and the social care leader will then arrange for an awake staff that will be with the service user throughout the night. With regards to other service user in the house, we always organise outings with them like bowling, going to the pub and so on just to keep them away and they can have a break as well.
Another service user in the house with moderate intellectual disability present challenging behaviour as a way of seeking attention. This service user is so much attached to a particular staff and when the staff is not working, the service user’s behaviour is completely different compared to if the staff is on duty. If the staff is on duty, the service user would want the staff to always be with her and attend to all her needs. However, if other staff tries to make the service user understand that the staff is busy for example, writing a report or giving personal care to other service user, the service user will become abusive and her tone of voice will be very high. Whenever the service user is in that mood, other service user in the house will be upset. The staffs use Behaviour Modification on the service user. Behavioural Modification according to Atherton (2011) is the approach used by behavioural psychologists to modify behaviour. It is usually based on the reinforcement of desired behaviours and ignoring undesired ones. Therefore, the staff uses a Star Chart for the service user to modify the service user’s undesired behaviour so whenever the service user is being aggressive to other staff because the service user’s favourite worker is not there, the service user’s sticker will be taken off and the service user has to earn it back with good behaviour unless the service user will be in trouble with her key-worker and the social care leader, because all the service user wanted was for the staff to come down and then the service user will be calm. This service user does not behave like this when another staff is on duty.
Training courses in the management of challenging behaviour may help to provide carers with the belief that a person can cope with the violent and aggressive behaviours. This increase in confidence can increase the likelihood that a person with learning difficulties will have the opportunity to have access to ordinary community service (Blunden and Allen 1987; cited McDonnell 1997:160). This is because the reputations that people with challenging behaviour acquire can affect their relationship with their carers. Literally, you cannot have a positive relationship with a service user who frightens you. Training can help to build a relationship of trust between the client and the carer (McDonnell 1997:160). Particularly, staffs working in social care setting need more support and training in challenging behaviour because it is the key to identifying and maintaining the equilibrium of challenging behaviours being presented by the service users.
An innovative approach to challenging behaviour is counselling. Counselling as defined by Elliot and Place (1998) is the process of listening to problems, advising on actions and explaining the constraints within which children and adult should operate. It is associated with paying attention to non-verbal cues, developing good listening skills establishing trust, maintaining positive attitudes, developing expectations and showing non-judgemental attitudes and respect for privacy (Papatheodorou 2005:56). Dave (1989) Carpenter and Apter (1988) went on and say that counselling aims to enable the client to increase their conscious awareness of distorted perceptions of existing realities, and to provide emotional support in order to reduce their level of frustration (Elliot and Place 1998; Dave 1989; and Carpenter and Apter 1988; cited Papatheodorou 2005:56). Counselling in this sense will work very well with the service user that uses challenging behaviour as a mechanism of seeking attention to the particular staff. It will be a good idea if the service user’s key worker arranges for an appointment with a counsellor because it will make the service user not only to understand that the staff is not just there to attend to her but to other service users in the house which will change the service user’s behaviour and attitude on it.
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Operant approaches have stressed the importance of the environment in causing and maintaining aggressive behaviours (Skinner, 1953, 1957; cited McDonnell 2010, 2). Reinforcement of behaviour, both positive and negative, has a causal effect on antecedent stimuli and behaviour. However, there is little doubt that the application of scientific approaches to behaviour analysis has led to significant positive developments in care settings. Early approaches tended to focus on the manipulation of consequences to behaviours and the use of token economy system to control and manage behaviours can provide some insight into the change and adaptation of behaviour technologies. Token economies tended to be used in larger institutionalised system in the past (Ayllon and Azrin 1968; cited McDonnell and Sturmey 2010: 5). This approach can be found in a social care because some service users might not like the house that he or she is living in, maybe due to other service user’s behaviour towards him or her and this can increase the likelihood of aggressive and challenging behaviour.
If the behaviour of staff inadvertently triggers aggressive behaviours, then altering these behaviours may have an impact on the management of aggressive behaviours. The construct of reflective practice in which an individual evaluate their performances in situations and learns from both positive and negative experiences (Schon, 1987) is useful to apply to staff who may experience violence and aggression in care settings. It is possible by staff, although in many cases they may be unaware of their influence. In the circumstances, it may be difficult to expect staff to examine their own contribution to these situations (Schon, 1987; cited McDonnell 2010: 20). This explanation shows the second scenario in this essay that the staff might have contributed to it, for example initially the staff might be showing too much attention to that particular service user and then the service user became too attached to the staff and the only way the service could get attention by the staff is by employing challenging behaviour towards other staff and service users when ever the staff is on duty. According to McDonnell 2010: 21) behaviour management strategies need to develop a questioning approach to managing behaviours, which should include an honest and critical appraisal of the staff member’s contribution to violence, aggression, and challenging behaviour. In order to achieve this, encouraging an open dialogue in human services about the role of staff beliefs and expectations in maintenance of aggressive behaviour is crucial.
A low arousal approach is predominantly a staff based intervention which focuses on reducing arousal in crisis situations. Organisationally there is am emphasis on strategies which aim to reduce confrontation through primarily staff based reduction of arousal. Immediate staff-based strategies focus on the reduction of requests and demands and on the non-verbal cues and triggers employed by staff in conflict situations. A general reduction of rules and boundaries which may also create a culture of control are implicit aspect of the approach (McDonnell 2010: 24).
De-escalation offers a nonviolent way to manage disruptive and assaultive behaviour. The technique can be used in all types of health care organization. A number of well-known programmes offer a consistent approach to the safe management of out-of-control behaviour. One general programme is Nonviolent Crisis Intervention provided by Crisis Prevention Institute (CPI). Another technique is Time-out which is a procedure used to help individual regain emotional control by removing him or her from the immediate environment and restricting him or her to a quiet area or unlocked room. It generally involves a brief of standard duration, such as 5 minutes or 20 minutes. Brief isolation (through a time-out) provides more learning trials and opportunities to see the consequences of behaviour. Time-out can be used very effectively as part of an early prevention programme (Joint Commission Resources 2002: 50-52).
Having gone through several books and websites, it is understood that staff might contribute to upsetting behaviour towards the service user thereby invoking challenging behaviour. Nevertheless, challenging behaviour is a serious issue among children, and people with intellectual disability especially those in residential home care. There are some techniques and strategies for example the low arousal approach, the time-out approach, Nonviolent Crisis Intervention, outlined in this essay which can help both the service user and their carers to be ware of their own behaviours which can trigger aggressive behaviour in others.
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