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Challenging Behaviour

Background

As all children grow up there are times when they show difficult or inappropriate behaviour. Challenging behaviour is a term that is used to describe particularly "difficult" or "problematic" behaviour, which is experienced as challenging by parents and others who care for and support these individuals. Challenging behaviour is more common in individuals with learning (intellectual) disability and autism spectrum conditions than in those without; approximately ten percent of children with learning disability exhibit severely challenging behaviour.

Those with physical, emotional, social and communication difficulties may also show behaviour that is worrying, difficult or challenging. A person's underlying medical and/or psychiatric condition, age, social experiences, adverse life events and a range of other factors can affect the type of behaviour.  Occasionally an underlying cause, for example genetic, may leave the individual prone to challenging behaviours of varying intensity and nature.

Credits

Last updated July 2019 by Professor J Turk, Emeritus Professor of Developmental Psychiatry, Institute of Psychiatry Psychology & Neurosciences, King's College, University of London, and Consultant Child and Adolescent Psychiatrist, Community Child and Adolescent Mental Health Service, Isle of Wight NHS Trust.

Although great care has been taken in the compilation and preparation of all entries to ensure accuracy, we cannot accept responsibility for any errors or omissions. Any medical information is provided is for education/information purposes and is not designed to replace medical advice by a qualified medical professional.

What are the symptoms?

There are many types of behaviour that can be described as challenging. Examples of these include:

  • self-injury
  • physical aggression
  • verbal aggression
  • hyperactivity and extreme impulsiveness
  • extreme fluctuating mood swings
  • disruption and destruction of property or the environment
  • stereotyped behaviours (e.g. rocking, jumping up and down, twirling)
  • inappropriate or unacceptable sexual behaviour
  • smearing and urination
  • stealing
  • manipulative, deceitful and non-compliant behaviour
  • chaotic and disorganised hyperactivity
  • absconding.

What are the causes?

Challenging behaviour can result from many factors, often several simultaneously. Some children with learning disability (intellectual disability) lack the communication and emotional skills to convey what they need. A child may show certain behaviours to communicate that they are experiencing physical or emotional discomfort. It is important to exclude physically distressing symptoms such as pain.  Assessing behaviour may also be part of the process to diagnose an underlying condition. There are a few conditions in which certain types of behaviour may be more common, such as Lesch Nyhan syndrome, Prader-Willi syndrome, fragile X syndrome, Cornelia de Lange syndrome, Smith-Magenis syndrome and autism. However, not all children with the same condition will necessarily show a particular behaviour.

How is it diagnosed?

For behaviour to be defined as "challenging", the nature of the behaviour, its seriousness, intensity, duration and frequency must all be observed, preferably in a number of different locations, times and others present. A combination of observations and reporting by parents, other carers, school staff and other professionals needs to occur.  As well as a detailed description of observed behaviours, there should be details of possible "triggers" ("antecedents") as well as possible responses to the behaviour ("consequences") which may be helping to address it, or conversely may be maintaining or even increasing it.

Some people feel that it is inappropriate to label a child as having challenging behaviour as it can be caused as much by the way the child and their family interact and are supported as by the child's characteristics. The label of "challenging behaviour" can have a negative impact and this must be considered carefully during assessment sessions.

 

How is it treated?

Most challenging behaviours are best managed without medication. The most effective types of interventions will take into account what social, developmental, biological, language and communication, and psychological factors are affecting the child's behaviour. Any causes of physical or psychological pain or distress need to be identified and treated vigorously. Any adverse experiences including extreme ones such as abuse and neglect must also be identified and addressed.  With appropriate levels of stimulation, care, support and encouragement, and teaching of new coping skills, for example problem-solving, anger management and information processing, behaviour can usually be kept within acceptable limits. Professionals may conduct a "functional assessment" to find out the needs which are being met by the behaviour and what its "communicatory function" is. This is done to help identify ways to prevent and respond to behaviour, encouraging more productive behaviours instead. The aim is in part to try to teach the child alternative and more acceptable ways of getting their needs met as part of a positive behaviour support plan. Although this method will require much time and effort, positive improvement in behaviour will be seen provided these strategies are used all the time, wherever the individual is, and by all who come into contact with the child (e.g. both at home and school). Treating or otherwise managing underlying medical conditions and addressing sensory and communication needs are also essential to having a positive effect on behaviour. With good support, most challenging behaviour can be reduced to a level whereby it does not impinge on the individual's and family's quality of life.

Inheritance patterns and prenatal diagnosis

Inheritance patterns
Some conditions that include challenging behaviour as a feature may be genetic and have a specific inheritance pattern (see above) although challenging behaviour itself is not inherited.

Prenatal diagnosis
Prenatal diagnosis of the underlying condition may be possible for some causes of challenging behaviour. The type of testing will depend on the condition.

Is there support?

Challenging Behaviour Foundation

Family support line: 0300 666 0126
Email: support@thecbf.org.uk
www.challengingbehaviour.org.uk

The Foundation in a Registered Charity in England and Wales No. 1060714, established in 1997. It provides information and support to families and professionals caring for individuals with severe learning disabilities who are described as having challenging behaviour. The Foundation has both a parents email network and a professionals email network and also a wide range of free resources available for families.

Group details last confirmed July 2019.

References

Cooper P, Smith JS, Upton G.Emotional and behavioural difficulties: theory to practice. 1994; London, UK: Routledge.

Clements C, Martin N.Assessing behaviors regarded as problematic for people with developmental disabilities. 2002; London, UK: Jessica Kingsley.

Emerson, E.Challenging Behaviour: analysis and intervention in people with learning disabilities. 2001; Cambridge, UK: Cambridge University Press.

McGill P.An introduction to challenging behaviour[e-text]. Available at: http://www.challengingbehaviour.org.uk