1

Behaviour Management versus Behaviour

Change: A Useful Distinction?

Andrew McDonnell, Ph.D. Clinical Psychologist,

Studio 3 Training Systems,

Bath,

UK.

and

Honorary Research Fellow,

Department of Nursing and Midwifery,

Stirling University.

And

Regine Anker

Studio 3 Training Systems,

Bath,

UK.

Address for correspondence: Andrew McDonnell PhD, Studio 3 Training Systems, 32

Gay Street, Bath, BA1 2NT, UK.

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“In the long run we will all be dead!”

(John Maynard Keynes, 1883-1946)

The above quotation was attributed to a famous economist who was concerned that

too much emphasis was placed on long-term economic policies rather than short-term

solutions to more immediate problems or crises. This review will focus on a similar

dilemma in the area of behavioral psychology and the short term versus long term

solutions for individuals who present with challenging behaviours. We will argue that

the distinction between behaviour management and behaviour change strategies is

useful for both practitioners and researchers.

Challenging behaviours

Challenging behaviours have remained a major topic of concern for many years in

services for people with developmental disabilities. Emerson (1995) defines

challenging behaviour as: "culturally abnormal behaviour(s) of such an intensity,

frequency or duration that the physical safety of the person or others is likely to be

placed in serious jeopardy, or behaviour which is likely to seriously limit use of, or

result in the person being denied access to ordinary community facilities.” (Emerson,

1995, p.4). This definition places the focus on services and social systems rather than

individuals. Challenging behaviours are a function of a service or system, and

consequently interventions must take account of ecological variables, as opposed to

viewing the target behaviour in isolation (Donnellan et al. 1988).

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The Impact of Challenging Behaviours

Challenging behaviours have been implicated in the breakdown of family placements

(Rousey, Blacher and Haunerman, l990), placement in more restrictive settings such

as institutions (Hill and Bruininks, 1984), breakdown of community placements and

subsequent readmission to hospital services (Allen 1999; Lakin, Hill, Hauber,

Bruininks and Heal, 1983). Challenging Behaviour may be associated with specific

diagnoses. A recent meta-analytic review of 86 studies on challenging behaviours

identified risk markers of challenging behaviours (McClintock, Hall and Oliver,

2003). In the case of aggression these risk markers included a higher prevalence of

males with a diagnosis of autism and deficits in expressive communication.

Challenging behaviours give rise to injury to carers and peers (Hill and Spreat, 1987)

and may in some circumstances be associated with high staff turnover and lower job

satisfaction (Razza, 1993; George and Baumeister, 1981). These behaviours may

furthermore result in injury to clients when attempts are made to restrain them and

thus may provoke physical abuse from carers (Rusch, Hall and Griffin, 1986). This

may reflect a subjective interpretation of the importance of challenging behaviours to

staff that work 'in the front-line'. The need for advice and training on how to manage

these behaviours and for carers to defend themselves non-violently, whilst also

ensuring client safety, has been acknowledged (Allen, MacDonald and Doyle 1997;

Rusch et al. 1986).

Staff emotional responses to Challenging Behaviours

Challenging behaviours can evoke powerful emotional responses in individuals

(Oliver, 1993) and can generate fear among care staff who are often expected to

manage such behaviours in their day-to-day work. Singh, Lloyd and Kendall (1990)

4

dramatically stated that “they may physically attack others, children and adults with a

fury that elicits the label of a Banshee; they may throw heavy objects such as

televisions across rooms regardless of whom the object hits” (Singh, Lloyd and

Kendall, 1990, p.3).

The Development of Positive Behavioural Supports

Fuller (1949) applied operant technology to the shaping of a motor response in a

young man with developmental disabilities. This led to the emergence of the

application of behavioural technology in care settings. Early behavioural intervention

strategies tended to focus on consequence based strategies. Over the last two decades

there has been a substantial move away from consequential punishment based

interventions to those based on reinforcement contingencies (Lerman and Vorndran,

2002; Donnellan et al. 1988; LaVigna and Donnellan 1986). Positive behavioural

support is a development of applied behaviour analytic interventions which state that

“to remediate problem behaviour, it is necessary first to remediate problem contexts.

There are two kinds of deficiencies: those that relating to environmental conditions

and those relating to behaviour repertoires” (Carr et al. 1999, p4).

Carr et al. (1999) concluded that positive behavioural supports were widely applicable

to a variety of care settings and that stimulus based interventions were becoming more

commonplace than reinforcement based procedures. They concluded that “modest to

substantial increases in positive behaviour are typically observed following the

application of positive behavioural supports” (Carr et al. 1999, p4). Scientific

approaches to human behaviour such as positive behaviour support approaches have

had a major impact on services for people labeled with learning disabilities

(Parmenter, 2001).

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Evidenced Based Behaviour Management: The Cinderella Area

Crisis interventions are a critical component of community supports for people with a

learning disability who present with aggressive behaviours (Hanson and Weiseler,

2002; Lakin and Larson, 2002). Carr et al. (1994) maintained that crisis interventions

are needed “It is a mistake to think that once an intervention is underway, you no

longer need to worry about serious outbursts and the necessity for crisis management”

(Carr et al. 1994, p.14). Research reviews have presented a relatively optimistic view

of behavioural interventions although the majority of this literature reports studies that

are relatively short-term in nature (Ager and O'May 2001; Didden, Duker and

Korzilius, 1997; Scotti, Ujcic, Weigle, Holland and Kirk, 1996; Emerson, 1995;

Emerson, 1993). Furthermore comparatively few individuals‟ behaviours were

successfully changed in these studies (Reiss and Havercamp, 1997). In sum,

challenging behaviours are likely to be long-term and not necessarily changed by

transferring people from hospital to community housing (Emerson and Hatton, 1996;

Felce, Lowe and DePaiva, 1994). Involvement of specialist behavioural input may not

always prevent the breakdown of placements (Allen, 1999). There is also some

evidence, which suggests that interventions do not always appear to maintain

behaviours (Whitaker, 2002). Indeed, challenging behaviours are now acknowledged

to be extremely complex in nature (Felce and Emerson, 1996).

Distinguishing behaviour management and behaviour change strategies

Despite the increasing improvements in positive behavioural support technology

incidents involving physical aggression will be likely to occur for a significant

proportion of individuals with a learning disability. Behavioural change outcomes are

not necessarily the only goal and short-term management of aggressive behaviours

6

has been acknowledged to be important in the literature (LaVigna and Willis, 2002;

Willis and LaVigna, 1985). For the short term management approaches the expression

'crisis procedures' has been adopted by some authors (LaVigna and Donnellan, 1986).

In a book entitled 'Progress without Punishment' (Donnellan, LaVigna, Negri-

Schoulz and Fassbender, 1988) the authors briefly mention a distinction between

'changing or managing challenging behaviours' although no definition of behaviour

management was provided.

Oliver (1993) in a review of self-injurious behaviours argued strongly that a

distinction should be made between a response and a strategy. Presumably strategies

involve a longer-term treatment approach. Thus, if an operant response is not replaced

with alternative responses, then lasting behaviour change is unlikely to occur.

Responses are short-term approaches to behaviour that are limited in their focus.

Similarly, a distinction has been made between behaviour management and

behavioural treatment goals (Gardner and Cole, 1987). The objective of behaviour

treatment is to produce “enduring behaviour change that will persist across time and

situations' (Gardner and Moffatt, 1990, p.93).

Behaviour management is intended to reduce the frequency or intensity of aggressive

behaviour without necessarily producing enduring change in the individual. Carr,

Levin, McConnachie, Carlson, Kemp, and Smith (1994), argue that without an

educational component behavioural change cannot be achieved by crisis management

procedures. Similarly reactive strategies require proactive components to alter

behaviour (LaVigna and Willis, 2002). However, if behaviour change is defined

more narrowly as a reduction in the frequency of target behaviours, then under such a

definition behaviour change could arguably occur in the short term. The problem with

this argument is that behaviour change would be almost impossible to define and

7

research. While this distinction would appear to have a degree of 'face validity', the

vast majority of research has tended to focus on behavioural treatments and

interventions.

The confusion in terminology would appear to require clearer operational definitions.

For the purposes of this article a behaviour change strategy “involves changes in

intensity, frequency or episodic severity that maintain across situations and time”.

Behaviour management involves “strategies which contain a behaviour and reduce

the risk of harm to service users and staff without attempting to alter the behaviour

per se”. In this definition reductions in intensity, frequency or episodic severity of

challenging behaviours may occur but the primary goal is one of safety and

containment. Therefore, physical interventions, most pharmacological management,

mechanical restraint, seclusion and isolation would be behaviour management

strategies.

Behaviour management strategies are an essential component of behavioural

interventions. This is particularly true of interventions that involve extreme

behaviours. Challenging behaviours have been noted to increase after the

implementation of behavioural interventions (Iwata, Pace, Cowdrey and Miltenberger,

1994). There are two common side effects. First an „extinction burst‟ can occur

where there is a temporary increase in the frequency, duration or magnitude of a

target behaviour. Second extinction induced elicited aggression can occur (Lerman,

Iwata and Wallace, 1999; Lerman and Iwata, 1995; Azrin, Hutchinson and Hake,

1963). In Lovaas and Simmons (1969) classic study one of the subjects did not

participate in the extinction part of the experiment due to the risks of severe self-harm

that may have resulted during the process. The severity of these 'bursts' has led to

some authors recommending the wearing of protective headgear and clothing for care

8

staff in extreme circumstances (Ducharme and Van Houten, 1994). It is therefore

implicit in any intervention that behavioural excesses may have to be managed in the

short-term before long-term results can be achieved. However, people who are

confronted by potentially aggressive individuals may be forgiven for concerning

themselves with short-term crisis intervention. The removal of an aversive stimulus

such as aggressive behaviour can be a powerful reinforcer (Oliver, 1993). Coping

strategies that manage increases in aggressive behaviour are an important component

of any behavioural intervention. Punishment procedures may appear to be quite

attractive to staff as they rapidly suppress target behaviours (Lerman and Vorndran,

2002).

Pharmacological management

Pharmacological approaches have probably been the most widely used approach in

the field of learning disability to manage aggressive behaviours. In a survey of 625

service users in Canada, 54% of the sample were receiving medication for behaviour

control purposes (Feldman et al. 2004). Emerson, Robertson, Gregory Hatton,

Kessissoglou, Hallam and Hillery (2000) in a sample of 500 people in the UK and

Ireland found that antipsychotic medication was more than three times as likely to be

the treatment of choice than written behavioural programmes. Polypharmacy, that is

the multiple administration of similar classes of medication, is not an unusual practice

in learning disability services (Lott, McGregor, Engelmann, Touchette, Tournay,

Sandman, Fernandez, Plon and Walsh, 2004; Spreat, Conroy and Fullerton, 2004;

Robertson et al. 2000; Kiernan, Reeves, and Alborz, 1995). It is also much easier to

operationally describe drug treatments.

9

Kroese et al. (2001) suggested that the prescription of medication for behaviours or

aggression, without considering the functions of these behaviours, represents a poor

use of drug-based therapies. Paradoxically many professionals who work in the fields

of learning disabilities tend to prefer behavioural interventions as opposed to drug

based therapies; this however does not appear to be reflected in day-to-day practice

(Emerson et al. 2000; Robertson et al. 2000). Longer term pharmacological

interventions may lead to behaviour change as defined in this article. It can be unclear

to practitioners whether these types of interventions are predominantly behaviour

management strategies.

Emergency medication clearly falls within the category of behaviour management.

Emergency medication involves the application of medication to achieve rapid control

of aggressive behaviours. Roberston, Emersom, Gregory, Hatton, Kessissoglou and

Hallam (2000) reported evidence about the administration of such drugs in a PRN

manner. PRN (as and when required) medication is used in a number of services in

the UK, however its role appears to require more scrutiny. There appears to be a wide

range of dosages adopted throughout services in the U.K. Sedation would appear to

be the main rationale for the usage of drugs in this manner.

Physical Restraint

Physical restraints are behaviour management strategies used to manage

predominantly aggressive behaviours. Physical restraint is defined as “actions or

procedures which are designed to limit or suppress movement or mobility” (Harris,

1996, p100).

The physical restraint of people who present a danger to themselves or others, may

well be socially undesirable but at times a necessity. Studies have shown that restraint

10

can act as a positive reinforcer in some instances (Favell, McGimsey and Jones,

1978).

Physical restraints are still used in services for people with a developmental disability.

A study of aversive procedures in Minnesota found that physical restraint, especially

manual restraint was the most commonly used management procedure in community

settings (Nord, Wieseler and Hanson, 1991). Emerson et al. (2000) in a survey of 500

people in the United Kingdom and Ireland labelled with challenging behaviour

reported 23% of the sample had experienced physical restraint. A similar survey of

disability services in Canada reported that 13.3% of a sample of 625 service users had

physical restraint as a component of their intervention plan (Feldman, Atkinson, Foti-

Gervais and Condillac, 2004).

It is perhaps not surprising that physical restraint methods have been employed by

care staff to manage aggressive behaviours, and still remain in use in both hospital

and community settings (Emerson, 2002; Harris, 1996; Nord, Wieseler and Hanson,

1991). To date, we understand very little about the use of physical behaviour

management strategies.

Mechanical restraint

The use of mechanical restraint to manage self injurious behaviour is documented in

the literature (Oliver, 1993). Mechanical restraints can involve protective arm splints,

head gear and protective cuffs or mittens. Mechanical restraint on its own is unlikely

to remove the risk of self injury as when the devices are removed the behaviour is

likely to continue to be exhibited by the person (Paley, 2008). The use of these

devices does raise serious ethical issues. There is comparatively little research which

investigates the effectiveness of these methods (Jones, Allen, Moore, Phillips and

11

Lowe, 2007). Mechanical restraints are by our definition behaviour management

strategies as they do not directly alter the underlying causal mechanisms. In cases of

very severe or life threatening self injury their use may be required.

Seclusion/Isolation

Sailas and Wahlbeck (2005) defined seclusion as “the placement and retention of a

person in a bare room either by locking the door or by stationing staff at the door to

ensure the person remains inside”. It‟s use in developmental disability services

appears to be predominantly in hospital based services (Mason, 1996). The practice of

seclusion meets the definition of a behaviour management strategy. Seclusion is used

in psychiatric services and has been a subject of research interest (Whittington,

Baskind and Paterson, 2006). There is comparatively little research about it‟s usage in

developmental disability services.

Reducing Restrictive Behaviour Management Practices

There has been an increasing focus on the reduction of restrictive practices (Deveau

and McDonnell, 2008). Some authors are even now suggesting that the lack of

empirical evidence should not be a barrier for restricting the use of strategies such as

physical or mechanical restraint (Sturmey, 2008). In Europe there has been an

increasing emphasis of the rights of people being cared for in the least restrictive

environment available and the least restrictive treatment available taking into account

their health needs and the need to protect the safety of others (Council of Europe

2004).

Strategies for reducing the usage of restrictive physical interventions appear to be

quite limited. Staff training in physical interventions has been widely adopted in the

12

UK (Deveau and McGill, 2007); despite the fact that there is limited evidence that

staff training approaches reduce the usage of such methods (Allen, 2001). There are

many policies and practices in organisations which may maintain the use of restrictive

physical interventions (Deveau and McDonnell, 2008).

Social Validity

Behaviour management strategies need to be designed within a socially valid

framework (Wolf, 1978). The aversive / non-aversive debate would appear to have

produced a polarisation of views. Outcome measures are increasingly being

broadened to include constructs such as social validity (Wolf, 1978). Behaviour

management strategies that involve physical responses to challenging behaviours

should be examined within this context. Baker and Allen (2001) highlighted that high-

risk service users may be at risk of abuse from staff using physical interventions.

There is a growing literature which involves the views of people with developmental

disabilities about behaviour management (Hawkins, Allen and Jenkins 2005; Sequeira

and Halstead 2001). Two qualitative studies report strong emotional reactions of

service users to physical interventions (Fish and Culshaw, 2005, Sequeira and

Halstead, 2004). A recent study of the views of service users and staff experiences of

physical interventions in the UK reported discrepancies between staff and service user

views of physical interventions. Staff reported using the methods in a non punitive

manner whereas some service users reported that they felt that they were being

punished (Fish and Culshaw, 2005).

It is the contention of the authors that a focus on both the empirical and moral

arguments for behaviour management strategies should lead to a greater emphasis on

13

their reduction. More research is needed which investigates the social validity of a

wide range of behaviour management strategies.

Do all behaviours need to be changed?

One argument which has to be considered within the context of managing and

changing challenging behaviour is whether all behaviours need to be changed. The

advances in behavioural technology and the use of PBS (Carr et al. 1999) provide a

reasonably extensive „toolkit‟. Behaviour change should always be a desirable

outcome, but for some individuals behaviour management may be sufficient per se.

Consider the example of a young man with autism who repeatedly asks the same

question to staff. Changing this behaviour may involve a range of strategies such as

long term redirection plans, teaching a functionally equivalent response, altering a

response chain all with a view of eliminating the above described behaviour. From a

behaviour management perspective if the young man repeats the question 20 or 30

times before he can continue with an activity, does that really require an intervention?

In contrast repeated use of physical interventions or mechanical restraints would be

undesirable if they remained unaltered.

Conclusion

Staff who support people with challenges in a variety of care settings need to be able

to manage crises effectively (Allen, 2001). In this article we have examined the

distinction between behaviour change and behaviour management strategies. We have

created two modified definitions and applied this distinction to a variety of behaviour

management strategies. It is our contention that this distinction has great heuristic

value for families, staff and professionals.

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We make this distinction to highlight the need to bridge the gap between research and

day to day practice. The development of more effective behaviour management

technologies would therefore benefit researchers (Allen, 2002). There is clearly a

paucity of data about the use and reduction of behaviour management strategies in

services for people with developmental disabilities. We stress that effective behaviour

management should not be viewed as an alternative to behaviour change strategies.

However, if we develop a better understanding of their use and reduction there are

clear benefits to consumers.

15

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