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For 20 years Charlie's challenging behaviour went unchecked. But Dr Mariangela Bati and her learning difficulties support team recognised it as his way of initiating social interaction. Graham Hopkins reports

The name of the service user has been changed

CASE NOTES
PRACTITIONER: Dr Mariangela Bati, behaviour analyst, Adepta.
FIELD: Behaviour support team, learning difficulties.
LOCATION: Stanmore, north west London.
CLIENT: Charlie Craig is a 40-year-old man with severe learning difficulties and limited verbal communication skills.

CASE HISTORY: Charlie lived his early life with his family but, although they still have a close relationship with him, they could not cope with him at home. For the past 20 years he has had a variety of placements, some of which have broken down due to his challenging behaviour.

About two years ago he was moved again – this time into a community home for four people run by Adepta, a charity that helps people with learning difficulties, autism or mental health problems make the most of opportunities within their communities. 

However, even this specialised service struggled to manage Charlie’s physical aggression and disruptive behaviour. And yet another placement was edging towards breakdown.

DILEMMA: The service aims to provide community-based support but Charlie’s behaviour is denying him opportunities to take part in activities outside the home.

RISK FACTOR: If his challenging and sexually inappropriate behaviour continues, the placement may be in jeopardy and may even lead to being sectioned under mental health legislation.

OUTCOME: With the success of Charlie’s behaviour support plan, his challenging behaviour is now minimal and his quality of life has greatly improved.

It is thought that up to one in seven people with learning difficulties have some form of “challenging behaviour” which may put their own or others’ health and safety at risk.

Challenging behaviour often starts in early childhood. If it continues into adulthood the danger of being labelled as “challenging” intensifies and the focus can shift away from discovering the cause of the behaviour to simply that of managing outbursts as they happen.

However, research shows that dealing with the cause of the behaviour is the most effective way of working. Generally, challenging behaviour can be viewed as an attempt by a person to regain some control over their life or because they are  frustrated at their inability to make others understand what they want.

For more than 20 years Charlie Craig’s challenging behaviour saw him shifted from one service to another, all unable to cope.

But in reality it was Charlie who could not cope with the people around him not understanding his feelings, wishes and choices.

Within two months of arriving at a community home run by the charity Adepta, Charlie’s placement was once again in jeopardy. The manager made an urgent referral to the behaviour support team (BST).

“Charlie was grabbing staff and residents around their necks; he’d slap and kick people,” says behaviour analyst Mariangela Bati. “He’d disrupt the environment by slamming doors, banging windows and throwing objects. He would touch female staff members on the breasts. He would approach staff from behind and thrust his groin into them. He would pull up staff skirts and pull down the trousers of other residents.”

The BST’s assessment indicated that Charlie engaged in challenging behaviour as a way of prompting people to interact with him. This was further supported by the fact that he had few socially acceptable ways of initiating interaction, and that incidents usually occurred when he was left alone and unoccupied.

A behaviour support plan focused on enhancing communication, activities and structure.

“Although Charlie could sign a few things in Makaton – like ‘mum’, ‘dad’, ‘phone’ – he didn’t have any ways of expressing his needs,” says Bati. “He loved his photographs and could point out family members. So we took photographs of different items that represented different activities, such as shoes, a kettle and so on.”

Charlie was also given a board where staff would either show him what his next activity was or present him with up to three photographs to choose what he wanted to do. “We found out very quickly – within 15 days – that not only could he clearly understand what was going to happen but also that it enabled him to choose what he wanted. He began going to his folder of photographs and choosing the activity he wanted to do and show it to his keyworker.”

There was often a period of time between Charlie getting up and getting ready and the bus arriving to take him to a day service, during which Charlie had nothing to do. A morning routine was set up; being engaged minimised his chances of resorting to challenging behaviour. “The other time was the coming home routine,” adds Bati. “We found that this, which was also a staff handover time, was when incidents were more likely to occur.

So staff would greet him home with a handshake and suggest he put his coat away; then they would make a cup of tea with him because he loves tea and biscuits; and then they would go for a walk because Charlie loves walking. These walks would also help him calm down.”

Bati also assessed Charlie’s inappropriate touching. “I found from my observations that rather than being sexualised behaviour it was his way of initiating interaction,” she says. “He would do that if others were talking and he wasn’t included. So we taught him to shake hands – a more socially acceptable way of initiating interaction. Staff prompted him to shake people’s hands as they left or entered – but within three weeks they no longer needed to prompt Charlie. And after that there were no more  incidents of inappropriate touching.”

Before the support plan, staff were recording up to 14 critical incidents a month. Within three months this had dropped to one or two. “It was amazing – he was a very quick learner,” says Bati. “I have to recognise the excellent work of the staff team – because the successful implementation of any support plan is 90 per cent down to the manager and staff.”

ARGUMENTS FOR RISK
● Adepta’s approach assumes that challenging behaviour is purposeful; that it has a function. In this case they identified a reason (a wish to interact) for Charlie’s behaviour. This meant that a specific support plan could be put in place.
● By focusing on enhancing communication, activities and structure, and teaching Charlie new skills, the support plan (including developing a more systematic way of supporting him at key times of day, increasing activities, communicating through photographs, and teaching Charlie to greet people by shaking their hands) would enable him to meet his need for interaction in a socially acceptable way.
● The staff team began to recognise the signs that he was about to engage in challenging behaviour – such as Charlie screaming, biting his hand, sucking his right index finger, a twitching in his mouth. “At these times staff take him into different rooms to go through his family photograph album to settle him down,” says Bati.

ARGUMENTS AGAINST RISK
● Charlie’s challenging behaviour had been deep-seated since childhood. His losses of placements are testament to that. This recent placement was also in danger of breaking down. There is no doubt that the worst case scenario would have seen Charlie sectioned under the Mental Health Act 1983. His challenging behaviour, including his physical aggression and inappropriate sexualised behaviour, was increasing the risk of supporting him in the community. Placing him in hospital would have protected himself and others.
● If the behaviour support plan had failed to work or if Charlie had significantly hurt himself or others while the plan was being carried out, questions of accountability and responsibility would ultimately have been raised.
● While displaying various challenging behaviour he was also limiting his opportunities to take part in activities, both at home and in the community – thus restricting his own quality of life.

INDEPENDENT COMMENT
For more than 20 years Charlie’s challenging behaviour saw him shifted from one service to another, writes Kathryn Stone. Has it really taken us that long to work out that Charlie is trying to tell us something?

I wonder whether all those who had worked with Charlie before he went to live where he is now are reading this case study. And if so, what do they think?

Perhaps some reflection on their part might be in order.

Mariangela Bati’s intervention sounds so simple. So simple and yet so effective. It is truly astonishing that no one before Dr Bati had thought of trying to get to the root of what made Charlie behave in the way he did. The home is to be commended for calling in the experts and for working so closely with Dr Bati to support Charlie. Staff could have so easily given up but their belief in Charlie and in their ability to support him have really shone through. 

I wonder whether a focus on managing behaviour misses out any consideration of emotional life and how this is being addressed. Charlie’s “inappropriate touching” may well be his expression of his sexuality: how is he supported to do this now and express how he feels without it being considered “challenging behaviour”?

If we say how we feel – be it angry, happy, sad and so on – that is acceptable. But if we show it then that can be interpreted as “difficult”.

I really hope that Charlie continues to enjoy his new life and that others, including his mum, dad and family, start to enjoy being with him.

Kathryn Stone is chief executive of Voice UK, a national learning difficulties charity

Contact the author
Graham Hopkins

This article appeared in the 23 November issue, under the headline "Lighter touch saves the day"