Responding to Behaviour of Concern

1. Introduction

Dealing with behaviour of concern which is exhibited by adults with care and support needs can be frustrating and difficult for all those concerned, but particularly the adult, and their family.

Such behaviour can mask other emotions, feelings, physical illnesses that the adult is experiencing. It should always be considered that behaviour of concern may occur for a number of different reasons, especially as they may not be able to express themselves verbally which may cause them considerable distress. It is vital therefore that, once the incident of behaviour of concern has been resolved in the short term, that staff consider other possible causes of such situations and work with the adult to reduce or prevent further incidents  occurring.

This chapter outlines some of the causes, effects and strategies for dealing with behaviour of concern.

2. Types of Behaviour of Concern, Potential Causes and Effects

2.1 Types of behaviour of concern

There are two main types of behaviour of concern that adults may exhibit towards staff, other adults who use the service or family and friends.

First is verbal abuse. This can include:

• derogatory comments which are racist, homophobic and / or of an uncomplimentary personal nature;
• threats of physical violence;
• bullying and emotional abuse;
• other types of non-verbal abuse.

The second is physical abuse. This can include:

• physical assaults carried out on others;
• physical assaults including the use of any type of weapon;
• damaging or destroying other people’s property or belongings;
• damaging or destroying items in the environment;
• damaging or destroying property and / or furniture;
• different types of illegal behaviour, including graffiti, noise nuisance etc.

2.2 Criminal offences

These types of behaviours may mean that the adult has committed a criminal offence. Where staff have such concerns, the manager should contact the police. In the case of physical abuse, staff should contact the police immediately via 999 if the concern requires an immediate response to protect people or property.

2.3 Causes or triggers of behaviour of concern

There may be a number of different physical and emotional reasons why an adult displays behaviour that causes concern. These include:

• discomfort and / or pain caused by illness, including constipation for example;
• influence of alcohol and / or drugs;
• long term personal factors, for example a disability that prevents verbal communication, movement or behaviour;
• temporary environmental factors, such as living in temporary accommodation that they do not find appropriate;
• persistent environmental factors for example being exposed to excessive and / or prolonged noise;
• being frightened or scared about their circumstances or a perceived or actual potential threat;
• being physically, sexually or emotionally abused or neglected by others.

2.4 Potential effects of behaviour of concern

The potential effects of an adult displaying behaviour which causes concern include being or feeling isolated from family or friends, physical injury, receiving a criminal record, social exclusion, financial and employment consequences.

Whilst every effort should be made to recognised the cause of the behaviour and work with the adult to reduce or prevent incidents of such, it is also essential that staff support the adult to recognise the effects of their behaviour on others, as well as the consequences for themselves.

Supporting adults to understand the impact of their own personal power, particularly physical strength or verbal attacks, is key to helping them manage their behaviour.

3. Strategies for Responding to and Dealing with Behaviour of Concern

There are a number of different approaches that can be useful for staff, and family and friends, in managing an adult’s behaviour. Strategies include:

• effective communication, including talking to the adult in a reassuring and calm manner, particularly if it is felt that the situation may start to escalate;
• person-centred planning, which puts the adult at the centre of the process;
• promoting self-esteem, particularly in adults who have low self-confidence;
• supporting the adult to develop coping strategies in relation to particular anxieties or stresses they experience;
• positive behaviour management, including reinforcing positive behaviour– the use of rewards for positive behaviour or sanctions for negative behaviour;
• ensuring rules and boundaries apply equally to all adults who use services, and their family or friends;
• following organisational procedures;
• management of the aftermath of the event;
• conflict resolution, particularly between the adult and another adult who uses the service, or family / friends;
• providing active support and encouraging adults to seek support – including identifying who may provide that support – when they are feeling worried or anxious;
• use of cognitive behaviour therapy and behaviour modification programmes;
• use of medication, which may include pain relief, or management of anxiety or depression;
• ABC (antecedent behaviour consequence) charts;
• using restraint (see Restraint) – this should be a last resort where all other options have already been tried;
• using medication – this should also be a last resort, where all other options have already been tried.

If there is any concern about the adult’s mental capacity, a mental capacity assessment should be completed if one has not already been done (see Mental Capacity chapter).

4. Recording

See Record Keeping

All incidents should be recorded in the adult’s case file and in other relevant documentation, such as incident records.

5. Management Reporting

Incidents should be reported to senior managers, as appropriate. Where staff are not sure who to report incidents to, they should seek advice from their line manager or duty member of staff.

6. Staff Support

All staff should receive training, relevant to their position in the service. Staff training should include techniques such as diversion, de-escalation, responding to challenging situations. It should also include the importance of staff attitudes and responses to an adult exhibiting behaviour of concern, as this is vital in managing such circumstances.

Remaining calm and controlled when provoked is essential to effective management of behaviour that causes concern.

Staff de-briefing following situation is vital, not solely in relation to staff support but also about learning from incidents, including what may have been done differently and useful information to prevent further events. It should be clearly documented how any learning is shared with other workers and across the organisation. Such information is key to risk assessment and care and support plans reviews and ongoing one-to-one keywork with adults, as appropriate.

Staff supervision also plays a vital role in effective management. This gives the member of staff opportunity and time to express how they feel about particular situations, and managers should offer support as appropriate, including additional training were required.