Changes in Attributions as a Consequence of Training for Challenging and Complex Behaviour for Carers of People with Learning Disabilities: A Systematic Review

Changes in Attributions as a Consequence ofTraining for Challenging and ComplexBehaviour for Carers of People with LearningDisabilities: A Systematic ReviewSophie Williams*, Dave Dagnan�, Jacqui Rodgers� and Kathryn McDowell�

*Northumberland Head Injury Service, Northgate Hospital, Morpeth, Northumberland, UK; �Cumbria Partnership NHS Trust,

Community Learning Disabilities Service, Lakeland Business Centre, Workington, Cumbria, UK; �Department of Clinical

Psychology, University of Newcastle, Newcastle upon Tyne, UK

Accepted for publication 10 September 2011

Aim This paper reviews the evidence for changes in

carers’ attributions regarding the behaviour of people

with intellectual disabilities as a consequence of carer

training in challenging and complex behaviour.

Method Papers were included in the review if they

reported outcomes for carer training on the behaviour of

people with intellectual disabilities and used a measure

of carer attribution of the behaviour of people with

intellectual disabilities. The characteristics of the scales

used and the content and length of training are consid-

ered as possible factors affecting changes in attribution.

Results Eleven papers were reviewed, most studies using

behavioural curricula for their training, and none explic-

itly set out to change attributions. Eight of the 11 papers

reviewed reported changes in attribution although core

characteristics of training did not distinguish those

papers that reported such changes and those that did

not.

Conclusions Changes in beliefs and attributions occur

even though these are not identified as a focus within

the training provided. The present authors suggest that

the formulation processes involved in behavioural train-

ing may play a key part in changing attributions as a

consequence of this training. The present authors dis-

cuss the potential for more focussed intervention

designed to change attributions and for better alignment

of measures to specific attribution change expected as a

result of specific training approaches.

Keywords: attribution, challenging behaviour, staff, train-

ing

Introduction

There is significant evidence for the efficacy of behavio-

ural intervention in the management of challenging

behaviours of people with intellectual disabilities (e.g.

Ball et al. 2004; Grey & Hastings 2005). Consequently,

there is considerable interest in the provision of training

to support the development of carer skills in this area.

However, it has been suggested that the optimum

implementation of effective behavioural strategies may

not be solely dependent on acquiring the necessary

skills, but also acquiring belief systems and explanations

that are consistent with the skills being taught (e.g. Ager

& O’ May 2001). This paper is a review of studies of

training in challenging behaviour that have included

measures of staff explanations or causal beliefs about

the challenging behaviour of service users.

A fundamental assumption of the behavioural

approach is that behaviour is primarily affected by con-

ditions existing in the person’s environment (Reese,

Hellings, & Schroeder 1999). Consequently, during

behavioural training, staff are often taught the essential

elements of analysis of behaviour, which include defin-

ing the target behaviour, antecedent conditions and the

consequences of the behaviour as well as the setting or

context in which the behaviour occurs to understand the

causes and function of the behaviour. Once the function

of the behaviour has been established, effective behavio-

Journal of Applied Research in Intellectual Disabilities 2012, 25, 203–216

� 2011 Blackwell Publishing Ltd 10.1111/j.1468-3148.2011.00654.x

Published for the British Institute of Learning Disabilities

ural strategies can be developed, which focus on sys-

tematically changing one or more of these elements in

an attempt to increase helpful or decrease challenging

behaviour. ‘Positive programming’ (La Vigna & Donne-

llan 1986) interventions will often be complex and car-

ried out over long periods of time. Consequently, staff

need to be equipped not only with the necessary skills

to apply behavioural approaches but also with the moti-

vation to sustain the interventions, often despite contin-

ued challenges from services users. The cognitive and

emotional responses of staff working within this context

have therefore gained considerable interest.

There is a growing literature examining the impact of

carer cognition on motivation and behaviour. A number

of studies (e.g. Dagnan & Cairns 2005) have focused on

Weiner’s motivational model derived from attribution

theory (e.g. Weiner 1980; Weiner 1985, Weiner 1995),

which has an underlying assumption that the attribu-

tions that staff make about the causes of behaviour

influence their emotional and subsequent behavioural

responses. For example, Allen (1999) suggested that

there is a general tendency to attribute challenging

behaviour to internal causes believed to be in the indi-

vidual’s control, such as emotion, and speculated that

lowered motivation is likely to result from staff’s belief

that there is nothing they could do to influence such

behaviours. A recent review has identified a number of

methodological weaknesses in studies applying Weiner’s

model to care staff supporting people with intellectual

disabilities who present with challenge behaviour (Will-

ner & Smith 2007). Thus, the applicability of Weiner’s

model to this population remains tentative; however,

the potential clinical utility of this model sustains its

popularity.

The overall aim of this paper is to critically review

studies of staff training in challenging behaviour, which

include measures of staff belief about challenging

behaviour. Three specific objectives include:

1. to review the key constructs and measures utilized in

studies to identify the theoretical assumptions underpin-

ning them;

2. to determine whether studies suggest that cognitive

change occurs in carers as a result of training;

3. to make suggestions for future research and clinical

practice that would focus on developing staff cognitive

change in challenging behaviour training.

No date limits were set for the studies included in the

review. Searches were carried out to identify all studies

that have examined staff training in challenging or com-

plex behaviours, and identified papers were then

searched to determine whether they had included a

measure of belief about challenging behaviour. A num-

ber of studies measured cognition in other domains

such as self-efficacy (e.g. Lowe et al. 2007) or optimism

(e.g. Kalsy et al. 2007) however, for this paper, only mea-

sures of attribution or explanation of challenging behav-

iour, are considered. The present authors discuss the

distinction between types of cognition measured in par-

ticular scales later in this paper. However, at this point,

the present authors define the core construct of ‘belief,

attribution or explanation’ as a cognitive structure that

explains the causes of challenging behaviour. The pres-

ent authors do not include measures of knowledge in

this definition and make a distinction between beliefs

and knowledge identifying that knowledge refers to the

‘representation of a proposition’, whereas a belief is the

‘representation of a truth-value associated with a propo-

sition’ (Griffin & Ohlsson 2001). Thus, measures

included here offer either degrees of endorsement of a

statement or alternative propositions, regarding the

causes of a behaviour. For the study to be included, the

training had to be aimed at supporting staff working

with service users who present with challenging or com-

plex behaviour. No exclusions were made however

regarding training content (e.g. the majority of studies

focus on behavioural approaches, although others are

primarily related to a specific presentation such as

dementia) or duration. The search strategy identified

approximately 70 articles for which abstracts were

reviewed. From this set of studies, 20 were obtained for

more detailed evaluation against the above-mentioned

criteria. Following this, a final sample of 11 studies was

obtained for the inclusion in the current review. Key

characteristics of the selected studies are presented in

Table 1. The present authors emphasize later in this

paper that none of the training studies reviewed explic-

itly set out to alter cognition or belief although some

identify values as a key aspect of the training they deliv-

ered. The present authors do not regard values as syn-

onymous with attributions or causal explanation

although they may be functionally related; values are

broad ethical constructs, which may functionally associ-

ate with specific beliefs around a specific event or a

class of behaviours that may be regarded as challenging,

but which are not at the same level of specificity.

Although this distinction is important, in fact, none of

the studies reviewed include a measure of ‘values’

although some explicitly address values in the training

curricula described (e.g. Dowey et al. 2007).

Three key areas in these studies are considered with

respect to their impact upon change in cognition: the

key cognitive constructs referred to and measures used

204 Journal of Applied Research in Intellectual Disabilities

� 2011 Blackwell Publishing Ltd, 25, 203–216

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on

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arn

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ativ

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ifica

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T1–

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Tab

le1

(Con

tin

ued

)

Stu

dyS

ampl

eT

rain

ing

con

ten

t

Des

ign

and

mea

sure

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enti

fyse

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ear

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rom

ote

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ls

of

care

Inst

rum

ents

mea

suri

ng

bel

iefs

abo

ut

chal

len

gin

gb

ehav

iou

r:

–C

on

trib

ute

top

erso

nal

cen

tred

pla

nn

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efin

ing

chal

len

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BA

(Has

tin

gs

1997

)

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stag

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ctiv

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up

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ou

nd

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of

com

mu

nic

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McD

on

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al.

(200

8)90

staf

fm

emb

ers

pro

vid

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for

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ally

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ing

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Tab

le1

(Con

tin

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Stu

dyS

ampl

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rain

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ten

t

Des

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and

mea

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geR

esu

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rum

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ut

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len

gin

g

beh

avio

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ntr

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ity

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iefs

Sca

le

(Dag

nan

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2004

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ill

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007)

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der

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lom

ain

1998

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0

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req

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and

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sis

Inst

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ut

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len

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elf-

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rio

us

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avio

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esti

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etal

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96)

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ear:

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nn

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idt

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rum

ents

mea

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len

gin

gb

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r:

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adap

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aco

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le1

(Con

tin

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Stu

dyS

ampl

eT

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con

ten

t

Des

ign

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in the studies, the content of the training courses and

the length of the training courses.

Key Constructs and Measures Used toDetect Change of Staff Cognition

The 11 studies included in this review used a variety of

labels for key constructs; these included attribution

(Grey et al. 2002a,b; Kalsy et al. 2007; McGill et al. 2007;

McKenzie et al. 2000), beliefs (Smidt et al. 2007; Tierney

et al. 2007), attitudes (Lowe et al. 2007), behavioural

understanding (Dowey et al. 2007) and cognitive repre-

sentations (Campbell & Hogg 2008). Despite the vari-

ance in labelling of key constructs, the same measure

was often applied. For example, Smidt et al. (2007) label

their key construct ‘staff beliefs’, and Lowe et al. (2007)

label theirs ‘staff attitude’; however, the primary mea-

sure applied in both studies was the Challenging Behav-

iour Attribution Scale (CHABA; Hastings 1997). Berryman

et al. (1994) key construct was also ‘attitude’; however,

the measure they used was ‘Causal Attributions for

Challenging Behaviour Scale’ (J. Berryman, Unpublished

masters thesis). Thus, the literature uses terminology for

cognitive processes and content relatively interchange-

ably.

A tool measuring staff’s cognition (attribution, causal

explanation, attitude and belief) focused on the challeng-

ing behaviour of people with intellectual disability had

to be used for the study to be included in this review.

The measures reported in studies within the review are

as follows:

The Controllability of Beliefs Scale (Dagnan et al. 2004):

This scale requires respondents to rate how much they

agree or disagree with a list of statements describing the

amount of control they think an individual has over

their behaviour. Examples of statements include ‘They

are trying to wind me up’, ‘They can’t help themselves’

or ‘They have chosen to behave in this way’. Dagnan

et al. (2004) report factor analysis of the scale that indi-

cates two distinct factors of high control and low con-

trol, acceptable levels of reliability and a degree of

construct validity. D. Dagnan, A. Hull & A. McDonnell

(unpublished data) have replicated this factor structure

with carers of people with intellectual disabilities. Two

studies in this review use this scale, and a significant

reduction in controllability ratings was evident

post-training in one study (Kalsy et al. 2007) although

no significant differences were evident in the second

(McDonnell et al. 2008).

The ‘Attributions about Challenging Behaviour Scale’

(McKenzie et al. 2000) uses a mixture of qualitative cod-

ing of attribution categories and a rating of attribution

on the dimensions of control, internality, stability and

specificity with respect to aggression, self-injury,

disruptive behaviour and stereotypy. The reliability and

validity of this measure are however only reported

within an unpublished doctoral thesis. The measure is

used in only one study, which found no significant

change in relation to attribution dimensions or attribution

categories immediately following training (McKenzie

et al. 2000).

Berryman et al. (1994) report the Causal Attributions for

Challenging Behaviour Scale in which respondents are

asked to provide reasons why a person described in a

vignette might have behaved as they did, as well the

type of treatment they believe should be implemented.

Two raters then categorized the responses according to

a selection of causal explanations and recommended

treatments evident in the literature including social rein-

forcement, medical problems or pain, communication,

skill deficit and psychiatric disorder. Acceptable levels

of inter-rater reliability are reported. This measure was

used in one study (Berryman et al. 1994), which reported

on two groups, attending a 1-day workshop in either

non-aversive approaches or traditional behaviour man-

agement strategies. The findings indicated that signifi-

cant change was seen in pre- and post-results in both

training groups with the group receiving the non-’aver-

sive principles’ training increasing their attribution of

escape ⁄ avoidance and positive reinforcement function.

The CHABA (Hastings 1997) was used in five of the

studies (Grey et al. 2002a,b; Lowe et al. 2007; McGill et al.

2007; Smidt et al. 2007; Tierney et al. 2007). The question-

naire requires the participant to rate a range of possible

causes of challenging behaviour; scales have been con-

structed to include causes learned behaviour (with sub-

scales for behaviour learned through both positive and

negative reinforcement), biomedical, physical environ-

ment, emotional etc. The CHABA has acceptable levels

of reliability, with estimates of Cronbach’s alpha for the

subscales falling in the moderate to good range. No

validity data are available. The five studies using this

scale included in this review report inconsistent results.

Of the two studies reporting significant change, Grey

et al. (2002a,b) report a post-training decrease in learned

positive attributions and increase in learned negative

attributions and self-stimulation attributions and Lowe

et al. (2007) report a post-training increase in learned

negative attributions. No attribution change was evident

in two studies (McGill et al. 2007; Tierney et al. 2007),

whilst Smidt et al. (2007) report a post-training increase

in all causal attributions except stimulation although the



significance of this was not tested. Interestingly, when

using two measures, McGill et al. (2007) found evidence

of significant post-training reduction in internal emo-

tional and a significant increase in correct behavioural

attributions in the Self-Injury Behavioural Understanding

Questionnaire (SIBUQ; Oliver et al. 1996) and significant

reduction in the CHABA emotional explanation sub-

scale.

The SIBUQ (Oliver et al. 1996) assesses not only cau-

sal explanations of the determinants self-injurious

behaviour (including behavioural and emotional dimen-

sions) but also technical and procedural knowledge and

the carer’s likely response to the behaviour. Acceptable

levels of tests–retest reliability for the total score and

most subtests have been reported (Oliver et al. 1996).

This measures was used in two studies, with both

Dowey et al. (2007) and McGill et al. (2007) reporting a

significant increase in behavioural causal explanations

post-training.

Finally, the Challenging Behaviour Representation Ques-

tionnaire (CBRQ) (Campbell 2007) is a theoretically

derived questionnaire, which draws on two existing

measures namely, the CHABA (Hastings 1997) and the

Illness Perception Questionnaire (Weinman, et al. 1996).

The resulting 40-item questionnaire has the following

subscales: identity, which is the label of the presentation

and ‘symptoms’ the respondent sees as being part of the

presentation; cause, which identifies personal ideas

about causes and development of the presentation; con-

sequences, which is the expected effects and outcome of

the illness; emotional reaction, which is how the presen-

tation affects the carer emotionally and treatment and

control which is the carers view of how one recovers

from, or controls, the presentation. These subscales offer

a broad, theoretically based view of how staff conceptu-

alize challenging behaviour and the subsequent emo-

tional response (Campbell 2007). Campbell (2007)

reports the challenging behaviour RQ to have acceptable

reliability (internal and test–retest) and a measure of

concurrent validity. The scale has been used in one

study in this review; Campbell & Hogg (2008) found

that the only significant changes following a substantial

distance learning course were in the cause and

treatment ⁄ control subscales.

Training Content

Owing to the convincing support for the efficacy of

evidence-based approaches derived from behavioural

analysis (Allen et al. 1997; Cullen 2000; Whitaker 2000,

2002), the majority of studies within this review

applied behavioural approaches at the core of their

training content (Berryman et al. 1994; Dowey et al.

2007; Grey et al. 2002a,b; Lowe et al. 2007; McGill et al.

2007; McKenzie et al. 2000; Tierney et al. 2007). The

content of these approaches frequently shared a com-

mon theme of trying to understand the function of

behaviour and identify factors contributing to it. Conse-

quently, the causal explanations a staff member may

attribute to a service user presenting with challenging

behaviour may change as they consider additional fac-

tors placed within a functional framework (e.g. Durand

1990). With the exception of McKenzie et al. (2000) and

Tierney et al. (2007), all the studies that included

behavioural approaches in their training content

reported significant change in staff’s causal explana-

tions immediately following training (Berryman et al.

1994; Grey et al. 2002a,b; Dowey et al. 2007; Lowe et al.

2007; McGill et al. 2007) or at 3-month follow-up

(Campbell et al. 2008). The only training with less

emphasis on understanding the causes of challenging

behaviour (McDonnell et al. 2008) showed no immedi-

ate change in staff’s controllability attributions about

challenging behaviour following training.

However, the two studies that did not include a

behavioural approach also found change in cognitions

immediately following training. In the study conducted

by Smidt et al. (2007), communication training was

utilized. Here, staff were encouraged to formulate their

own communication guidelines, which required them to

focus on challenging their attitudes and beliefs (Smidt

et al. 2007), which may be related to the reported shift in

causal attributions (although it is important to note that

this study does not report statistical testing of the

change in attributions). Kalsy et al. (2007) considered

how staff’s attributions about service users with intellec-

tual disability who suffer from dementia and sub-

sequent behavioural deficits (skill loss) or excesses (such

wandering) may change as a result of training in a psy-

cho-educational approach. The training offered informa-

tion on factors such as health problems associated with

ageing, background to dementia, prevalence and presen-

tation and course of dementia. Using the ‘Controllability

of Beliefs Scale’ (Dagnan et al. 2004), they found that

controllability ratings of staff towards services users

with dementia decreased as a consequence of training.

Kalsy et al. (2007) proposes that this reduction in con-

trollability attributions may have been influenced by the

descriptions of skill loss and cognitive change, which

may challenge staff views of the degree to which people

with intellectual disabilities and dementia have internal

control over their behaviour.



These findings suggest that introducing staff to a vari-

ety of causal factors that related to challenging behav-

iour could prove beneficial as it may facilitate a change

in understanding that is expressed as changed attribu-

tion.

Length of Training

The length of training was diverse ranging from brief

workshops of a day or less (Berryman et al. 1994; Dowey

et al. 2007; Kalsy et al. 2007; McKenzie et al. 2000) to

moderate length of 3–10 days (Lowe et al. 2007; McDon-

nell et al. 2008; Smidt et al. 2007; Tierney et al. 2007) or

more extensive training including nine full days over a

6-month period (Grey et al. 2002a,b), a 2-year part-time

training course (McGill et al. 2007) and a distance learn-

ing course requiring 64-h study time (Campbell et al.

2008). Shifts in causal explanations were evident in brief

(Berryman et al. 1994; Dowey et al. 2007; Kalsy et al.

2007), moderate (Lowe et al. 2007; Smidt et al. 2007) and

longer training (Campbell et al. 2008; Grey et al. 2002a,b;

McGill et al. 2007). However, although not directly

related to the duration of training, it is clear that those

studies that do not find cognitive change tend to be

those that have used the longest follow-up period (e.g.

Tierney et al. 2007; McDonnell et al. 2008). Thus, it will

be important that future studies explore factors that con-

tribute to the maintenance of cognitive change.

Discussion

The review has identified that the training reported in

many of the studies identified have resulted in some

change in carers attributions of the behaviour of people

with intellectual disabilities. Immediate change in causal

explanations following training was evident when the

training content involved exploring ‘causes’ of challeng-

ing behaviour (Berryman et al. 1994; Dowey et al. 2007;

Grey et al. 2002a,b; Lowe et al. 2007; McGill et al. 2007;

McKenzie et al. 2000; Tierney et al. 2007; Kalsy et al.

2007; Smidt et al. 2007). The present authors suggest that

further benefits may result if training were to explicitly

explore the particular causal explanations evoked and

their relationship to how staff feel about the about ser-

vice user’s behaviour (Dagnan & Cairns 2005). The pres-

ent authors suggest that the process of gaining

information that allows a reformulation of challenging

behaviour in general or of a particular person is a key

element in producing this change. However, it is diffi-

cult to identify this as a key factor from the studies in

this review as the majority of studies offer formulation

perspectives that encourage seeing a different under-

standing of challenging behaviour; thus, there is little

opportunity to compare to training that does not offer a

functional perspective. The only study that was not

explicitly a broadly ‘understanding’-based approach

(McDonnell et al. 2008) found no change in attributions;

however, it is not possible to draw conclusions based on

the results of a single study in this type of review. It is

possible that changes reported in training evaluation

studies are subject to social desirability effects. How-

ever, although this paper has focussed on measures of

cognition, other measures included in the studies

reviewed did not uniformly identify positive change. It

is interesting to note that measures of cognition seem to

be most sensitive to change in the training studies

reviewed here.

If training that does not focus specifically on changing

cognition and emotion is able to bring about short-term

change in beliefs, then training that requires staff mem-

bers to systematically consider how their thoughts

impact their emotions and behaviours may have addi-

tional impact. There are descriptions of methods that

may be used to familiarize staff with a cognitive–

behavioural understanding. Kushlick et al. (1998)

describe a method that combines elements of rational

emotive therapy (Ellis & Harper 1975; Ellis 1979) and

cognitive behaviour therapy (Beck et al. 1979). The

approach introduces the cognitive–behavioural model

and explores activating events from the workplace facili-

tating consideration of staff’s attributions about chal-

lenging behaviour and subsequent emotional and

behavioural reactions. However, a systematic evaluation

of the effect of introducing a cognitive behavioural com-

ponent to such training is needed (Kushlick et al. 1998).

It is notable that studies reviewed here include mea-

sures of cognition despite cognitive change not being a

specified outcome of training. It is possible to argue that

some of the measures included here, such as the CHABA

and the SIBUQ, are measuring behavioural ‘knowledge’

rather than attribution However, because they both offer

alternative explanations that are inconsistent with a

behavioural perspective but consistent with coherent,

alternative explanations, then they can be seen as a mea-

sure of endorsement of a behavioural explanation (rather

than representation of a proposition) and thus can be

regarded as measures of belief. However, the variety of

measures used to describe cognition causes problems in

interpretation of studies in this review. There is little

overlap in the core concepts measured in the scales that

are used in more than one study (CHABA; Hastings

1997; Controllability of Beliefs Scale, Dagnan et al. 2004;



SIBUQ, Oliver et al. 1996). Attributions are simply

defined as inferences regarding the causes of behaviour

(Heider 1958). From this perspective, all of these mea-

sures can be regarded as measuring attribution; however,

they each measure different aspects and ‘levels’ of attri-

bution. As with all cognitive theories, attributions can be

very specific (e.g. ‘they behaved in that way because they

were hungry’), broader explanation (e.g. a physiological

cause) or belong to a class of attribution (e.g. locus of

control). Each scale approaches this in a slightly different

way. The SIBUQ is designed to favour behavioural expla-

nation (i.e. learned behaviour), and although it will pro-

vide a score of emotion focussed and physiological

explanations, the questions for these scales are available

as alternative responses to the same question and so are

mutually exclusive; thus, a high score on behavioural

explanation is inevitably negatively correlated with any

one of the other scales, which limits its usefulness. The

scale is structured such that for each question, there is a

‘right’ answer from a behavioural perspective and,

although described as a scale measuring attributions, it

was mainly used in the studies reviewed here to measure

changes in behavioural explanation for training in

behavioural methods. The CHABA, on the other hand,

has a series of statements about possible causes of chal-

lenging behaviour, which divide into categories devel-

oped from studies of explanations from care staff, such

as emotion focussed, physiological focus, learned posi-

tive reinforcement and learned negative reinforcement.

In this scale, it is possible to get independent ratings from

these classes of explanation of behaviour. The Controlla-

bility of Beliefs Scale focuses on the single attribution

dimension of controllability, and it uses a series of state-

ments that each relate to the same dimension and thus is

focussed on a theoretically specific aspect of carer belief.

If a clear theoretical perspective was developed for the

cognitive content of training, then it would be possible to

match the specific focus of a training approach to the

measure used to identify change. For example, an

approach aimed at challenging beliefs of control or

responsibility for challenging behaviour could be effec-

tively evaluated using the Controllability of Beliefs Scale

(Dagnan et al. 2004), and an approach intended to

encourage a broad formulatory perspective might be bet-

ter evaluated using the CHABA (Hastings 1997).

Thus, the main conclusion from this review is that

training in challenging behaviour has a clear effect

upon cognitive variables, but that the present authors

cannot identify those aspects of training that have the

biggest impact upon cognition. A core part of training

for complex behaviour usually involves developing a

formulation of the person’s behaviour, whereby the ele-

ments of possible influence on the behaviour are

explored and their relationship to the behaviour is

understood. The present authors suspect that this is the

key aspect of training in changing cognition both in

developing a new construction of challenging behaviour

in general and in developing a specific understanding

of the behaviours of a named person. However, this

needs to be confirmed in future research. Service users

with intellectual disability and challenging behaviour

rely on staff supporting and caring for and supporting

them and staff attributions about challenging behaviour

may play a role in determining their emotional and

behavioural responses to such problematic behaviour

(Weiner 1995). Further research is needed to determine

whether a clear additional focus upon cognitions in

training results in different or better outcomes when

compared to training that solely focuses on behavioural

understanding of the client.

Correspondence

Any correspondence should be directed to Dave

Dagnan, Consultant Clinical Psychologist ⁄ Clinical Direc-

tor, Cumbria Partnership NHS Trust, Community Learn-

ing Disabilities Service, The Old School, Main Street,

Distington, Workington CA14 5UJ, Cumbria, UK (e-mail:

[email protected]).

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Documents

Changes in Attributions as a Consequence of Training for Challenging and Complex Behaviour for Carers of People with Learning Disabilities: A Systematic Review