MENTAL HANDICAP VOL. 12 DECEMBER 1984

DIFFICULT AND DISRUPTIVE BEHAVIOUR: 2. Adopting a problem centred approach

Robert Cameron Michael Shackleton Bailey John Wallis

Part 1 of this article described a study day on difficult and disruptive behaviour, organised by applied psychologists in health, social services, and education, for direct contact people who work with children and adults who are mentally handicapped. There are a number of sound reasons for making such a workshop available to a mixed group. These include:

1. Although increasing lip service is pa id to mul t id i sc ip l inary a p p r o a c h e s to p r o b l e m s , p ro fes s iona l t r a i n i n g f o r teachers, nurses, and social services care staff takes place in s e p a r a t e p ro fes s iona l departments.

2. Similar problems, for example, d i f f i c u l t a n d d i s r u p t i v e behaviour, occur in different settings.

3 . Some m o d e l s i n app l i ed psychology, especially those which originate in behavioural psychology, appear t o be applicable in different settings, and with different staff and client groups.

Part 1 of this article attempted to deal with the problem of reconciling the sometimes ignored needs of people who are mentally handicapped with the not to be ignored needs of direct contact staff. One use of the needs-intervention grid described was to show which interventions met the needs of both staff and clients. Another was to demonstrate that low technology interventions had surprising potential for meeting most people’s needs, especially those of clients.

It is worth remembering that some service delivery models that have been used to deal with the problems of difficult and disruptive behaviour in the past have been heavily criticised, both for their complexity and also because they often caused as many problems as they alleviated. Such criticisms has included the problems caused by labelling, the fact that remote or obscure explanations of

FIGURE 1. Different skills needed for different steps of the problem-centred framework

The skiits YOU need The problem centred framework

List assets

/ / -List deficits

To state behaviour clearly = -Select priority

\Clarify priority

Selective observation and recording Obtain baseline- - - -

Functional approach to behavioural change conditions

Identify the controlling

Task analysis Specify steps to desired outcome

Formulate intervention

Implement intervention Teaching and unlearning techniques

_ _ _ - - I I I I I I I I I I I I I I I I

Positive monitoring techniques Record and monitor intervention- -

Agree to terminate or re-negotiate contract with client

Troubleshooting and “gentle innovator” skills

the focus on “within the head” factors which cannot be changed, and the difficulties which arise from therapies which are not directly related to the problem in question.

As an alternative a problem-centred approach is offered. This approach argues that a careful examination of the events which surround problem behaviour can allow changes to be made in these events and so lead to a change in the behaviour of the client.

The problem-centred approach The problem-centred approach consists

of a simple, scientific model which enables the Dractitioner to : examine behaviour

priority; state the desired objectives; examine controlling conditions; and agree, implement, monitor, and evaluate the intervention chosen. In order to be able to complete the steps of the problem-centred framework a number of techniques are necessary. Both the framework and the techniques necessary are illustrated in Figure 1 and described in Westmacott and Cameron (1982) and Cameron and Stratford (1983).

The pre-requisite of the problem- centred approach is the need to state problems in clear and unambiguous language. In the study day the distinction between clear “performance” statements and unclear “fuzzy” statements is

causes do not lead to strategies for change, objekvely by clarifying problems; select a discussed at some lengih. The necessity for recording behaviour and obtaining baseline data is argued and the daily event The authors of this paper are applied psychologists working in record sheet (Figure 2) and the specific

Hampshire, in an education authority, social services department and incident sheet (Figure 3) are offered to health authority respectively. participants as useful ways of recording

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FIGURE 2. Daily event record sheet

What did I Where did 1 What do you h o k 1 Day I rhepemndo? it happen? provoked it?

FIGURE 3. Specific incident sheet

Name ....................................................................................................... Date: ........................... The problem Describe what the person actually did during the incident

How long did the behaviour last?

Staff member(s) involved

Antecedents What was the person doing prior to the incident?

What were the first signs?

What actually immediately preceded the incident? (e.g. what was the person asked to do)

Background Where and at what time did the incident take place?

Who else was involved (non-staff)?

Consequences How did the incident come to an end?

What did the member(s) of staff do after the incident?

Were any other members of staff involved at this stage?

What was happening ten minutes later?

information. Simple strategies for analysing and sequencing objectives are introduced, and the often daunting behavioural paradigm is simplified by demonstrating that behaviour is largely influenced by events which precede it (antecedents), the setting within which it occurs (background), and the events which follow it (consequences). (See Westmacott and Cameron (1981) or Cameron and Stratford (1983) for details of this approach.)

Effective (teaching) models within the A B C paradigm are examined, and participants are also shown how it is possible to genera te behavioural management strategies within the same model. Participants are then introduced to simple monitoring techniques which are designed to enable them to evaluate the outcome of their interventions and to pre- empt common problems which may occur.

At this point the study day is taken up with a group assignment in which participants, after viewing a video sequence of a violent incident, split into groups of 8 to 10 in order to practise using the specific incident sheet (to examine the incident in detai l ) and the needs intervention grid (to consider possible management strategies for the future). There is a short report back session.

Anticipating and responding to violence The study day then takes a look at what

is seen, by many staff, as the major problem - coping with violence as it is happening. This is certainly not an issue on which psychologists are uniquely qualified to speak. There are, for example, physical techniques of restraint which few psychologists ever need to know about but of which other staff, particularly nurses, may have had experience. Nevertheless the study day does not evade the issue and it tries to generate some strategies for coping with violence using a problem- centred approach. These are:

(1) changing the antecedents of violence;

(2) changing the background in which violence occurs;

(3 ) chang ing the immedia te consequences of violence;

(4 ) chang ing t h e long t e rm consequences of violence.

1. ANTECEDENTS. T h e antecedents of violence are

d i scussed u n d e r f o u r headings : envi ronmenta l effects ; “ internal conditions”; interpersonal factors; and faulty learning. It is emphasised that although violence is often assumed to be due to internal causes, which may be labelled mental handicap, brain damage, emotional disorder and so on, often the most important controlling antecedents of violence lie outside the person. The importance of anticipating and preventing violence is discussed, and the need for staff

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1. Describe the presenting problem. 2. Identify strengths. 3. Identify any other major problems. 4. Select priority problem. (Areproblemsrelated? Should Isrart with the easiest, or most annoying?

5. Write down the priority problem clearly and unambiguously. (Avoid fuzzy statements.) 6. Specify desired outcome (i.e. goal or objective) avoiding fuzzies. (Where possible: (a) specify

alternative desirable behaviours as well as elimination of undesirable behaviour; (b) check that attaming desired outcome would alleviate or overcome priority problem; (c) ensure that desired outcome is not incompatible with objectives of other people or the organisation or system as a whole.)

7. Obtain a measure of how frequently the priority problem occurs. Also, where applicable, obtain a measure of intensity and/or duration. (Note antecedent events, background - for example, place, time of day, people present - and consequent events. The specific incident sheedevent record may be useful in doing this.)

8. Use this information to write down the A B C of problem behaviour (i.e. Antecedent, Background, and Consequent events associated with the priority problem) as a framework for speculating on the controlling conditions associated with the problem behaviour and as an aid to listing possible interventions.

(a) the names of all the people affected by the problem behaviour (b) the needs of all the people affected by the problem behaviour (c) possible interventions.

other people’s needs as possible.

For whom is the problem a priority?)

9. Using the Needs-Intervention Grid, write down:

10. Check interventions against needs and select intervention which meets client’s needs and as many

11. Write down in clear, unambiguous language, a plan for carrying out the selected intervention. 12. Discuss and gain acceptance of plan by all involved, including client wherever practical. 13. Devise monitoring procedure for intervention. (Agree WHO will record; WHAT they will

record; and HOW (for example, tally or record sheet) they will record; WHEN they will record, and for HOW LONG they will record.)

14. Carry out intervention. 15. Monitor intervention. 16. If outcome of intervention successful, inform and congratulate all participants, after which either:

agree no further intervention necessary OR devise a “maintenance plan”, select the next priority problem, and repeat steps 5-16.

17. If outcome of intervention is unsuccessful either: agree a new intervention and repeat steps 10-15 OR re-negotiate desired outcome and repeat steps 6-15.

to know about clients’ personal histories and be sensitive to signs of imminent violence are highlighted. 2. BACKGROUND.

The background, or setting, may contribute to or even provoke violent outbursts. ,Suggestions on how to change both environmental and interpersonal factors in the background to minimise the likelihood of violence (or its effects) are discussed. Immediate strategies (like distraction) and preventive strategies (like providing competing and engaging activities) are noted. 3. IMMEDIATE CONSEQUENCES.

I n e x a m i n i n g t h e i m m e d i a t e consequences of violence the emphasis is on defusing the situation and restraint of the individuals involved. Under defusing, the key issues considered are body stance, eye contact, voice level and pitch, talking to gain control, not puttinga pupillpatienti client in a corner, and examining situations when the most appropriate strategy may be to “back down” in a disagreement. Under restraint, the importance of the use of minimum force, no threats, de-escallation, and isolation of the aggressor and/or victim are discussed. T h e importance of involving other members of staff is highlighted. 4. LONG TERM CONSEQUENCES.

Finally, the aftermath of the violent ou tburs t i s considered. Four key recommendations are: record; discuss; evaluate; and plan. In other words, use a problem-centred approach.

Feedback from the study day At the end of the day feedback is sought.

This has led to many improvements of detail, but comments have been generally very favourable. Assets frequently noted have included: relevance to everyday work, well-planned team presentation, humour, use of cartoons and video, group work, and participation of all three services (bo th as presenters and audiences). Deficits mentioned have included presentation of a great deal of material in one day, insufficient time for group work, and plenary sessions that are too short.

As a result of this feedback guidelines are being supplied to local supporting professionals for use when following up the study day with in-service training in schools, hospitals, adult training centres, or elsewhere. Also a set of study day materials has been provided which includes a 17-step summary of the problem-centred approach (see Figure 4). Participants are encouraged to try this out and invite a psychologist from their area to monitor their efforts.

One other outcome has been requests for the same information to be presented on an in-service basis. A number of workshops and induction courses have therefore been organised for two special schools; the nursing staff of a 400 bed

FIGURE 4. A summary of the problem-centred approach

mental handicap hospital; the staff of a brand new adult training centre and those of another established adult training centre; and for staff at a brand new hospital unit. In all these instances staff from a variety of professions have been involved in the organisation of the events.

The enormous advantage of all this activity is the opportunity it has offered for improvement of the study day itself, for which a flexible presentation has now been developed to meet the needs of various groups.

Discussion Although the content and format of the

study day continues to improve, and some of t h e ou tcomes have been very encouraging, a number of additional features have added an extra dimension. 1. Applied psychologists have begun to value the existence of a theoretical model which, unlike many models in psychology, has developed from practice rather than from an academic or theoretical base. 2. The radical behavioural model which is used overcomes many of the problems inherent in t radi t ional models of “behaviour modification”. Such models often had a “bad name” among direct contact people, not only because they

seemed to match techniques (such as Smarties, tokens, time out, and over- correction) to children rather than the opposite, but also because they focussed pr imari ly on the consequences of behaviour and largely ignored antecedents and setting conditions (see Cullen et al, 1977). 3. The problem-centred approach not only transcends client groups, agencies, and professional groups, but, excitingly, also offers a core curriculum in applied psychology. (See Cameron and Stratford (1 983) for a discussion.)

The Hampshire Standing Committee on Mental Handicap*, which began the study day, has carefully involved other applied psychologists in its presentation which has led to a number of additional exciting possibilities. As a group all these applied psychologists are very interested in triadic or pyramid training and are now studying ways of involving teachers, charge nurses, supervisors, and others in the presentation of the study day itself, with a view to these professionals eventually being able to hold s tudy days of their own for their colleagues. Another possibility which is

* see Part 1 of this article, and Westmacott, Cameron, and Wallis, (1981).

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being explored is the publication of some of the units of the study day as teaching packages, both for direct contact personnel and for supporting professionals in other disciplines. In short, what began as a modest piece of collaboration has become an exciting new development for applied psychologists, in which they have everything to gain and nothing to lose but their mystique.

Acknowledgement Acknowledgement is given to the work

carried out in planning the study day

__

described by the two other members of the Planning Committee, Adrian Faupel (Educational Psychologist) and John H a t t e r s l e y ( P r i n c i p a l Cl in ica l Psychologist). The following members of the Hampshire Standing Committee on Mental Handicap also made conmbutions: Valerie Barden (Principal Clinical Psychologist), Sue Bendall (Research Officer), Paul Chamberlain (Clinical Psycho log i s t ) , S t even H u g g e t t (Educational Psychologist), John Smith (Research Officer and Chairman of Standing Committee), and Elaine Westmacott (Educational Psychologist).

References Cameron, R. J., Stratford, R. J. A problem-

centred approach.to the delivery of applied psychology services. Accepted by J. Assoc. Educ. Psychol., 1983. In press.

Cullen, C., Tennant, L., Hattersley, J. Behaviour modifcation - some imphcatlons of a radrcal behavioural approach. Bull. Brit. Psychol. SOC.,

Westmacon, E. V. S . , Cameron, R. J. Behaviour Can Change. Basingstoke: MacMillan (Globe Education), 1981.

Westmacott, E. V. S., Cameron, R. J. Selling behaviourd psychology to parents and teachers. J. Assoc. Educ. Psychol., 1982; 59, 24-28.

Westmacott, E. V. S., Cameron, R. J., Wallis, J. M. Close encounters of a Hampshire kind: cooperation between psychologists. Bull. Brit.

1977; 30, 65-69.

Psychol. SOC., 1981; 34,420-421.

Communication and language in mental handicap 4. THE FOCUS ON

MEANINGFUL PRODUCTION

SUMMARY S o m e writers have recommended that work o n comprehension should take precedence over production when facilitating communication and language in children who are mentally handicapped. In contrast, the second article of this series suggested that the communication and language curriculum for children with severe learning difficulties should focus on meaningful production. This article seeks to justify this position, by discussing the relationship between comprehension and production in development, and by describing some of the drawbacks of working on comprehension.

Relationship between comprehension and production in development

McLean and Snyder-McLean (1978) state that, according to traditional wisdom, comprehension precedes production: that is, children understand words and grammatical features before they use them. Surprisingly, perhaps, this view is not reflected in what people do: researchers have paid more attention to production than comprehension (Bloom, 1974; Mittler, 1974b; Wheldall, 1976; Jones and Robson, 1979); and parents and teachers of children who are mentally handicapped are also more concerned with production (Mittler, 1974a, 1976; Jones and Robson, 1979). This is despite recommendations that work on comprehension should take precedence (Mittler, 1974a, 1974b, 1976; Jeffree and McConkey, 1976) and programmes based on that assumption (such as that of Fredericks et a)., 1976).

The greater research interest in production is partly because of problems with measuring understanding (Bloom, 1974). Production is certainly the more obvious, being directly observable, whereas comprehension involves covert behaviour which must be inferred (McLean and Snyder-McLean, 1978). This may also explain why parents and teachers focus more on production. Additionally, it is often tempting to believe, as many parents do, that a non-verbal child understands everything he hears (Wheldall, 1976).

Ian Bell

Many writers, including Renfrew (1964), Sheridan (1972), Horton (1974), Pateman (1974), Hargis (1977), and Stevens (198 l), have claimed that comprehension precedes production. Unfortunately it is not always clear what is meant by this. Wells (1981) is more specific: he notes that between 12 and 18 months of age most children comprehend far more words than they produce. There is also research evidence supporting the comprehension-before-production view. A frequently cited piece of work, now something of a classic, is that by Fraser, Bellugi, and Brown (1963). They presented pairs of pictures to three-year-old children. For each pair the child was asked to: (a) imitate a sentence describing one picture; (b) point to one picture in response to a sentence spoken by the investigator; and (c) produce a sentence to describe a picture. Fraser, Bellugi, and Brown concluded that imitation precedes comprehension, which in turn precedes production. Love11 and Dixon (1967) obtained the same result with two-year-olds.

However, Fraser, Bellugi, and Brown’s study has been widely criticised (Wheldall, 1976). Fernald (1972) believed that the scoring method favoured comprehension, and conducted his own research using a modified procedure. He found no significant difference between comprehension and production. Chapman and Miller (1973,1978) have also criticised the Fraser, Bellugi, and Brown study because of its scoring procedure. They too conducted their own research, finding that the production of subject-object word order precedes its comprehension.

Another piece of research supporting comprehension before production has been criticised. Shiplep, Smith, and Gleitman ( 1969, 1978) concluded that comprehension precedes production, but Bloom (1974) reviewed their work and disagreed with their conclusion, believing that their results

Ian Bell is the Deputy Headteacher at the Beaufort School, Coleshill Road, Birmingham.

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