Challenging Behaviour in Individuals with Learning Disabilities:

The Impact of Staff

Author: Jill McKnight

Introduction

‘Challenging behaviour’ is described as culturally abnormal behaviour with an intensity,

frequency and duration that places the physical safety of the self and others at serious risk

(Emerson, 2001). The term challenging behaviour (CB) incorporates a range of behaviours

including verbal and physical aggression, inappropriate social or sexual conduct, self-injury,

destructiveness, antisocial and disruptive behaviours, and stereotypical and repetitive

behaviours (Benson & Brooks, 2008; Grey & Hastings, 2005). Individuals with learning

disabilities (LD) are said to be 3 to 5 times more likely than the average population to exhibit

CB (Poppes et al., 2010). CB is likely to persist over time in these individuals and the more

severe or profound the disabilities, the higher the likelihood of CB being present (Cormack

et al., 2000; McIntyre et al., 2002; Totsika et al., 2008). Some studies document that

between 5% and 20% of individuals with LD display CB (Ball et al., 2004; Campbell, 2010;

Emerson, 2001; Kahng et al., 2002; Lowe et al., 1998), whereas other studies note

substantially higher rates (Allen, 2000; Cooper et al., 2009; Crocker et al., 2006). A recent

review of studies on aggressive behaviour reported that over 50% of people with

learning/intellectual disabilities display some form of aggression (Benson & Brooks 2008).

Rates of severe challenging behaviour have been reported to be 15% in the general

population of people with LD (Felce et al. 2009) and 22% in those residing in residential

services (Felce et al. 2011).

CB has consequences for the person exhibiting it and for the people in contact with that

person. For the individual it can result in denial of access to community facilities and

diminished opportunity to integrate, and can lead to physical injury and often restriction of

personal development (Emerson, 2001; Matson et al., 2008; Symons, 2008). More

specifically, aggressive behaviour has been reported to lead to exclusion from services,

breakdown of residential placements and involvement with the criminal justice system (e.g.

Allen et al. 2007). An individual with disabilities who presents with challenging behaviour

will also be at an increased risk for abuse, inappropriate treatment, exclusion, deprivation,

and systematic neglect (Emerson, McGill, & Mansell, 1994; Romeo et al., 2009; Sturmey,

2009). On the other hand, CB can pose a challenge for family, friends, carers and staff

interacting and working closely with the individual. CB is said to serve different functions

and is exhibited in response to individual factors (e.g. biological) but also environmental

factors (Emerson, 2001; Hastings, 2010). Some propose that environmental stimuli, such as

behaviour of others, particularly staff, are the main triggers (e.g. McGrath, 2013). Services

and support staff can in fact play a major role in the development and maintenance of CB

and the quality of their work is crucial to achieving good outcomes for service users

(Hastings and Brown 2000; Hastings, 2005, 2010; Lambrechts et al., 2008). Thus, there has

been an abundance of research and focus on staff factors in the literature and the role they

play regarding challenging behaviours in individuals with LD. Research to date has generally

followed two routes though: the first is on the notion that staff are problematic in their

performance, behaviours and attributions and the second route is on the emotional needs

of staff and the stress they experience. A third area which research has focused much less

on is staff-service user relationships. These will now be addressed in turn, concluding with

some ideas for future research.

The Impact of Staff on Challenging Behaviour

Staff behaviours and attributions

Staff are seen as problematic in their performance and behaviours in response to CB. Early

research documented that staff spend little contact time helping service users (Hastings &

Remington, 1994) and other research has found that making changes to the way support

staff behave can have a positive effect on service user outcomes (e.g. Grey et al., 2002).

Evidence of positive effects has been true for staff using positive behaviour support (PBS)

strategies and active support with individuals with CB (Totsika et al., 2008; Hastings, 2005).

One theme that has emerged in the last few decades has been the importance of staff

cognitive factors and the recognition that they play a role in staff performance and client

outcomes (Rose, 2011). Many researchers (e.g. Dagnan & Cairns, 2005; Stanley & Standen,

2000) have argued that Weiner’s (1980, 1986) ‘attributional theory’ can help us understand

staff’s emotional and behavioural responses to CB and how it is managed within services or

care programmes. This model of helping behaviour states explicitly the underlying

dimensional structure of causal attributions: locus, stability and control (Weiner, 1974). For

instance, if a negative outcome such as challenging behaviour is regarded as being under

the deliberate control of a person, we are likely to experience negative emotions and

reactions such as anger. However, if we judge that the individual was not acting

deliberately, and in fact lacked any control over their behaviour, we experience greater

sympathy or understanding.

Staff attributions in response to CB are important to acknowledge as Hastings and

Remington (1994) suggest that inappropriate staff attributions or beliefs about the causes of

challenging behaviour can result in the adoption of inappropriate interventions, strategies

and reduced helping behaviours (e.g. Oliver et al., 1996; Rae et al., 2011). Weigel et al.

(2006) found that staff can make the ‘fundamental attribution error’ in relation to

overestimating how much the individual with LD has control over their CB. This can lead to

higher levels of expressed emotion and negative or critical comments towards the service

user. Some studies, however, have provided results that do not demonstrate support for

Weiner’s attributional model applied to CB (e.g. Bailey et al., 2006; Wishart et al., 2013).

Reviews by Andrews, 2008, Lambrechts, Petry, and Maes, 2008 and Willner and Smith, 2008

have documented highly inconsistent findings and only partial support at best. Wilner and

Smith (2008) have argued that the inconsistency could be influenced by the limited

reliability of the largely vignette-based methodology, the fact that most studies fail to define

‘helping’ explicitly or to measure it adequately, and the possibility that attribution theory

might apply only to low-frequency behaviours. Questions over the reliability and validity of

the assessments used to measure attributions have also been raised (Andrews, 2008) and

an additional limitation may be the need to account for individual differences (Wishart et

al., 2013), such as personality traits of staff (e.g. Chung & Harding, 2009) as well as specific

behavioural topographies displayed in service users (e.g. Dilworth et al., 2011).

Work-related stress and burnout

The second route that research has focused on is the emotional needs of staff and that the

experience of supporting individuals with intellectually disabilities and challenging

behaviours can be stressful and emotionally challenging (Devereux et al., 2009; Hastings,

2002). To be the subject of verbal and physical abuse on an almost daily basis, as well as

being witness to self-injurious and other disturbing behaviours, can be common experiences

for many staff (Harris, 1993; McKenzie et al., 1999). Staff working with clients who are

experienced as challenging are reported to be more anxious and less satisfied with their jobs

than are other staff; feel less supported; are more likely to be emotionally exhausted and

suffer burnout (Jenkins et al. 1997); are more fearful about work-related violence (Mills &

Rose, 2011); feel less safe (Rose & Cleary 2007); and describe feelings of anger, guilt, self-

blame and powerlessness (Needham et al. 2005). However, there is something important to

observe here. Experiencing high stress levels as a result of CB can not only impact on the

psychological well-being of staff (Jenkins et al. 1997) but it can also impact the quality of

care staff are able to provide which will determine outcomes for service users (e.g. Rose et

al. 1998). Staff well-being may be determined by caring for challenging service users and the

stressors attached but the psychological and behavioural adjustment of service users may

be influenced by the well-being of staff (Hastings, 2010). Up until now research has adopted

a unidirectional approach in this area focusing solely on the effects on staff but a more

bidirectional approach should be central. What seems to be missing is a deeper exploration

and understanding of the reciprocal relationships between staff and service users.

Staff-service user relationships

McGrath (2013) has pointed out that staff-client interactions are reciprocal, whereby the

behaviours of clients affect those of carers, which in turn affect those of clients (Hastings,

2005). Client‑staff interactions may be influenced by the attributions, beliefs and

psychological resources of staff like those mentioned above. For example, the way staff

allocate their attention to clients can inadvertently shape and reinforce CB (Hastings &

Remington 1994b) and several studies suggest that negative staff-client relationships lead to

client aggression (Whittington & Wykes 1994, Duxbury 2002). What may be more important

though, and an element that the literature has neglected is the perceptions that staff have

of their relationships with service users and vice versa. How do support staff talk about and

perceive their interactions and relationships with the individuals they support? As we have

seen, research has tended to focus on a more negative perspective. But what about staff’s

positive perceptions of working with individuals with learning disability and challenging

behaviour? Hastings (2010) has pointed out, from the theoretical perspective of equity

models (e.g. Disley et al., 2009), that staff may derive benefits from their relationships with

service users with intellectual disabilities and this may apply to those with challenging

behaviour as well. One of the only studies to explore this is by Hastings and Horne (2004)

who found that support staff identified with a range of perceived positive contributions and

that these perceptions were associated with increased personal accomplishment at work

reported by the staff. Despite this, positive aspects of staff roles and relationships is

underdeveloped in the literature and methodologically and theoretically it is a clear priority

for research. Staff who can maintain perceptions of positive contributions may be able to

protect themselves from high-stress situations that may moderate the impact of work

stressors on staff well-being, which in turn may positively impact service users. It has also

been shown that staff with higher levels of confidence in their own professional abilities

care for individuals who develop and demonstrate greater self-determination, higher quality

of life, and social skills (Nota et al., 2007). Further exploration in these areas could therefore

be beneficial.

And what about the service users? We know that people with intellectual disability often

place staff at the centre of their perceptions of their social support networks and even their

friendships (e.g. Antaki et al., 2007). However, hardly any research in the area of challenging

behaviour and intellectual disability takes into account the perspective of the service users.

For example, in a review of staff training and working with individuals with intellectual

disability and challenging behaviour, there was no attention paid whatsoever to the

perspectives or experiences of clients (Van Oorsouw et al., 2013). Clients with mild to

moderate ID are certainly able to express their feelings about the quality of the care they

receive from staff (e.g. Clarkson et al., 2009; Roeleveld et al., 2011), so broadening the

research area and taking the perceptions of clients into account could certainly be of value,

in addition to looking at staff perspectives.

Future Research

It is clear from reviewing this literature that future research is needed (see Hastings, 2010).

Firstly, there is no doubt that measuring something as subjective as staff-service user

relationships is difficult and complicated. Researchers need to adapt and develop ways in

which dimensions of relationships between staff and service users can be measured. These

dimensions should include positive and negative constructs, and not just a focus on the

negative which research to date has tended to do. Likewise, we need to research service

user and staff perspectives of their relationships and find methods that allow individuals

with LD and CB that can report on aspects of their relationships, as this is a priority for

development (Hastings, 2010). Another problem here though is that staff often work with

multiple individuals that challenge and a way around this would also need to be addressed.

Another important issue is why support staff stay in their roles when aspects of their work

are stressful. Gaining answers here may be more important rather than exploring more

negative issues such as why staff become stressed and why they leave their working roles.

Lastly, there is room for additional research in the area of staff attributions. The criticisms

and methodological limitations of past research, such as questions over the reliability and

validity of the assessments used to measure attributions (Andrews, 2008) and the need to

account for individual differences (e.g. Chung & Harding, 2009; Dilworth et al., 2011;

Wishart et al., 2013), could be further explored and addressed in order to see if this

highlights any new findings which could aid and increase our understanding and knowledge

regarding the development and maintainence of CB in individuals with learning disabilities.

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