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making a difference to the lives of people with severe learning disabilities
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Functional Assessment (understanding the function of
the behaviour)
Mark Addison, Counselling Psychologist, Community Learning Disability Team, Somerset Partnership NHS and Social Care Trust.
When a child's behaviour has been identified as challenging, it is essential that a rationale is first provided as to exactly why it is challenging. Indeed, a problem for one person is not always a problem for another person. Sometimes the question must be asked, "Whose problem is it?" This is not to suggest that a difference of opinion should be ignored. Indeed, the fact that one person believes a behaviour to be a bigger problem than someone else, may simply reflect a limited knowledge about child development, or unrealistic expectations about how the child should behave. In this respect, some information and/or supportive counselling may be helpful.
A medical investigation should be sought to check for any possible underlying health influences. Common conditions such as ear infections, tooth-ache, constipation, urinary tract infections or epilepsy may all cause, or contribute to someone's challenging behaviour.
A functional assessment of the behaviour may provide some answers, or at least some theories, about the causes of the child's behaviour.
As noted in the Challenging Behaviour Foundation's 'Basic Information about Challenging Behaviour' information sheet, a functional assessment (sometimes referred to as a functional analysis) aims to shed light on the particular needs which a person gets met through their behaviour.
"It is not a matter of what causes self-injury or what causes aggression or what causes stereotyped or repetitive movements but for each of these difficult forms of difficult behaviour, what does it do for the individual, what purpose does it serve for them in their life?"
E. Emerson (quote from Brown and Brown, 1994)
By conducting a functional assessment, you are learning about people before you intervene in their lives. Hence, rather than basing interventions simply on 'hunches', 'trial and error', or 'what seemed to work for someone else', the functional assessment process should guide the development of a more objective and individually tailored intervention plan.
A functional assessment should include:
- A definition of the challenging behaviour in question: This is typically referred to as an 'operational definition' of the behaviour. Having a clear and concise definition of the behaviour (which may include specific examples of the behaviour as well as the frequency) is an essential prerequisite to a functional assessment. Indeed, as a functional assessment may consider observations/records/ideas from more than one person, it is important that everyone has exactly the same behaviour in mind. A good operational definition may also serve as a helpful reference in cases such as (a) a behaviour goes into remission but reappears at a later date; (b) an individual makes a transition from one support service to another (e.g., from child to adult service); or (c) a person experiences numerous changes in individual support staff. In addition to defining the challenging behaviour itself, it is helpful to define the 'early warning signs'. These simply refer to any behaviours that tend to occur prior to the challenging behaviour occurring.
- An assessment of the antecedent (i.e. what happens before) events: Certain things often appear to trigger challenging behaviour. What antecedent events (e.g., activities; settings; individuals; objects; thoughts; or feelings) are most likely to predict the occurrence of the behaviour? What antecedent events are most likely to predict the non-occurrence of the behaviour?
- An assessment of the consequent (i.e. what happens after) events: What is the person getting, or not getting from the behaviour that motivates them to do it again, and again and again? Many consequent events are externally motivating, e.g., the consequence of banging your head may be that you gain more or less attention from people; get a desired object, food or drink; or escape from an activity or task. However, consequent events may also be internally motivating, e.g., the consequence of banging your head when you are feeling bored, may be that you feel more stimulated.
Examples of additional factors that may be considered as part of a comprehensive functional assessment include: a person's communication abilities; their general likes and dislikes; their learning style (i.e., how do they learn best?); environmental factors (e.g., noise levels, time of day, unpredictable routines, or numbers of people); and the intervention history (i.e., has anything helped before?).
As a parent, or primary carer, you are most likely to experience one of the following two approaches to functional assessment, or perhaps both in combination.
The Indirect Approach: The indirect approach is so called simply because the methods are not based on the direct observation of the behaviour by the person who is carrying out the assessment. Instead, the assessment is based on the results of questionnaires, interviews, rating scales, or daily recording charts that have been completed by parents or primary carers.
The Descriptive Approach: In contrast to the indirect approach, the descriptive approach involves the direct observation of the behaviour, by the person who is doing the assessment, as it occurs in the natural setting, e.g., using a recording chart to record observations of the behaviour in the home, the school, or the supermarket.
A commonly used tool which may be used in both approaches, is known as the 'Antecedent, Behaviour and Consequence recording chart' (ABC chart).
Appendix 1 provides an example of an ABC chart which includes suggestions about the type of information that may be useful to include under each heading. Appendix 2 provides a blank chart which may be photocopied, and Appendix 3 provides a more traditional ABC chart format which will allow you to record more than one incident on each chart. The latter format is useful if the incidents occur quite frequently and/or in quick succession. If this is the case, it is advisable to include within your operational definition, some guidance on how to recognise when one incident stops and another one starts, e.g., an incident is recorded as a separate incident, when the behaviour has stopped for a minimum of 5 minutes before starting again.
Download the Appendix charts in pdf format
Ultimately, it is hoped that the repeated use of ABC charts may identify links between the behaviour, and it's antecedent and consequent events, that reveal or aid understanding of the function that a particular behaviour serves for an individual.
Although the process of using ABC charts is relatively straightforward, it can be complicated by the fact that the recording is often done by more than one person (e.g., parents, respite carers and teachers). In addition, a person's behaviour may actually serve more than one function, be used for different purposes in different locations and be responded to in different ways by different people. Once again, it is very helpful if all concerned decide on a good operational definition before people start recording.
What Function Does Challenging Behaviour Serve for People?
Although there are many reasons why a person may present with challenging behaviour, researchers and clinicians have found it helpful to consider function in relation to the following four categories:
- Social Attention: We have all heard the saying, "It's just attention seeking behaviour". It is not bad to want attention from others. Unfortunately, for a variety of reasons e.g., limited communication skills, boredom, poor self-occupation skills, some people may learn that behaving in a particular way is a reliable way of attracting others' attention, even if it is negative. For example, a child may find adult one-to-one interaction very rewarding, but at school has to share their teacher or assistant's time with the rest of the class. This child may learn that being incontinent is associated with an adult providing them with one-to-one attention in the form of helping them to clean up and change into dry clothes.
- Tangibles: Here it is the desire for certain things e.g., food, drink, objects or activities, which is providing the motivation for the behaviour. Again, it is not bad to want these things. If you are thirsty, it makes sense to try and get something to drink. If you want a bath, it makes sense to try and get someone to bathe you. However, problems arise when an individual learns to act inappropriately to get these things.
- Escape: Whilst some people crave attention, for some people being left alone is the ideal situation. Rather then behave in a particular way to get people's attention, these people will behave in a particular way to avoid situations or activities that they do not like, or do not find particularly rewarding. For example, a child that does not like group activities may learn that hitting the child nearest to them results in them being moved to a quiet corner on their own.
- Sensory: As previously mentioned, sometimes behaviour is internally rewarding, or self-reinforcing i.e. what is happening around the individual (externally) is not so important as what is happening inside the individual. For example, a person may behave in a particular way simply because of the sensation (e.g., rocking back and forth or banging their head), because it is stimulating (e.g., flapping a hand in front of a light or 'twiddling' a piece of string), or because of the way it sounds (e.g., grinding teeth together or clicking their tongue repetitively). These behaviours may appear pointless, annoying or distressing to the observer. However, for the person themselves, the behaviour may serve the function of helping them cope with uncomfortable negative feelings such as boredom or anxiety. Although a challenging behaviour may appear negative to us, the behaviour may serve as a positive coping strategy for the individual who has adopted it.
Outcomes of Functional Assessment
At the end of a functional assessment one would hope to have clarified, or at least generated some theories, about the function that a challenging behaviour serves for an individual. Indeed, the function that a behaviour serves has direct implications for how you respond to the behaviour. For example, you could decide to ignore a child's head-banging or respond to it in as neutral a way as safely possible. In the long-term this may lessen the behaviour in a child who bangs exclusively to gain attention (social attention motivated behaviour). However, the exact same strategy could worsen the behaviour in a child who bangs because they prefer to be left alone (escape motivated behaviour), since this response may reinforce the behaviour, i.e."I bang my head and people leave me alone". Obviously both children are communicating through their behaviour that they would like more or less attention, and it is important to listen to this. However, one must try and respond in a way that is not simply a direct reaction to the head-banging behaviour. Perhaps the first child would benefit from a higher level of one-to-one support as opposed to group activity? Would they benefit from being introduced to group activities on a more gradual basis? We are very busy - is the child more likely to get our attention when they are head-banging as opposed to when they are not? Are they enjoying what they are doing, or is interacting with people simply more rewarding than the alternative activity? Do they use this behaviour at home? Are there any early warning signs we can respond to that will allow us to give the child attention before they resort to head-banging?
Should we refer the child to a Speech and Language Therapist who may be able to advise on specific teaching and/or communication aids that will enable the child to get their point across in a less harmful way?
Any strategies that are introduced with the aim of stopping, reducing or encouraging alternatives to challenging behaviour, should be based on the results of the functional assessment.
The results of the functional assessment can form the basis of an individualised 'case-formulation'. A caseformulation simply refers to a set of facts or theories about why someone is behaving in a particular way.
What are the main factors that appear to be contributing to the continuation, or maintenance of the behaviour in that person's life?
Moreover, a case-formulation can provide a consistent focus for the essential process of reviewing and evaluating an individual's progress over time. Does the formulation still provide a reliable interpretation of why the child has challenging behaviour? Are carers/support workers responding to the behaviour in the most helpful way? Has anything changed? Is there a need to carry out further observations, or conduct another functional assessment? Should the formulation be updated?
It is important to recognise that challenging behaviour can occur for very complex reasons, and there will be individuals for whom those reasons remain unclear, even after a functional assessment has been carried out. Nevertheless, even a case formulation based on tentative theories can prove useful in the long-term.
Functional assessment is potentially a very useful process that can increase our understanding of an individual's behaviour. An increased understanding may enable us to make changes in the person's life that will result in a reduction in their challenging behaviour, or support us to help them to find alternatives to using their challenging behaviour.
For a more comprehensive description of the different approaches to functional assessment, including ABC chart recording see McBrien and Felce. (1992).
References
Brown, V., and Brown, H. (1994). Understanding and Responding to Difficult Behaviour. Pavilion
Publishing: Brighton.
McBrien, J., and Felce, D. (1992). Working with People who have Severe Learning Disability and
Challenging Behaviour: A Practical Handbook on the Behavioural Approach. BILD Publications: Avon.
Last updated: April 2000