The response to challenging behaviour by care staff: emotional responses, attributions of cause and observations of practice

Background Previous studies have attempted to apply Weiner's attributional model of helping behaviour to care staff who work with service users with intellectual disabilities and challenging behaviours by using studies based on vignettes. The aims of the current study were to investigate the application of Weiner's model to ‘real’ service users with intellectual disabilities and challenging behaviours and to observe the care staff's actual responses to challenging behaviours displayed by service users. Also, to compare care staff attributions, emotions, optimism, willingness to help and observed helping behaviours for self‐injurious behaviours in comparison to other forms of challenging behaviours. Method A total of 27 care staff completed two sets of measures, one set regarding a self‐injurious behaviour and the other regarding other forms of challenging behaviour. An additional 16 staff completed one set of measures. The measures focused on care staff attributions, emotions, optimism and willingness to help. Also, 16 of the care staff were observed interacting with the service users to collect data regarding their responses to challenging behaviours. Results For both self‐injurious behaviours and other forms of challenging behaviour, associations were found between the care staff internal, stable and uncontrollable attribution scores and care staff negative emotion scores. However, no associations were found between the care staff levels of emotion, optimism and willingness to help. Some associations were found between the care staff levels of willingness to help and observed helping behaviours. There were significant differences between the care staff attribution scores with higher scores being obtained for uncontrollable and stable attributions for other forms of challenging behaviours. No significant differences were found between the care staff emotions, optimism, willingness to help and observed helping behaviours. Conclusions The results did not provide support for Weiner's attributional model of helping behaviour. However, a preliminary model of negative care staff behaviour was derived from the exploratory analyses completed. This model proposes that there are associations between internal, stable and uncontrollable attributions and negative emotions in care staff and also between negative emotions and negative behaviours displayed by care staff in response to the actions of service users.     

Staff in services for people with intellectual disabilities: the impact of stress on attributions of challenging behaviour

Background There is a lack of a conceptual framework as to how stress and attribution variables interact and influence staff behaviour in response to challenging behaviour. To address this, a model is tested examining the impact of stress on attributions of challenging behaviour within Weiner's model of helping. Method A total of 107 staff working in community homes for people with intellectual disabilities completed a self-report questionnaire that measured stress, burnout, attributions, emotions, optimism and helping behaviour in response to challenging behaviour. Results Partial support was found for the role of attributions and emotions. However, although staff reported high stress levels and moderate burnout, this did not appear to relate to their reporting of thoughts and feelings regarding challenging behaviour predicted by Weiner's helping model. It was not possible to fully test the helping model, as the ‘help’ variable was not normally distributed. Conclusions There was little evidence to suggest that stress has a primary role in determining staff responses when examined within Weiner's model of helping. Limited support in general was offered for Weiner's helping model. Potential conceptual difficulties and clinical implications are explored and alternative models for future research are discussed.     

Staff responses to challenging behaviour shown by people with dementia: an application of an attributional-emotional model of helping behaviour

There is some evidence to suggest that staff beliefs and emotional responses to challenging behaviour shown by clients are critical factors in guiding their responses to such behaviour. The purpose of this paper was to apply Weiner's cognitive-emotional model of helping behaviour to staff working with people with dementia who exhibit challenging behaviour. The paper also aimed to explore the impact of staff burnout and professional group upon participants' responses to real-life experiences of challenging behaviour. The participants were 25 nurses and 26 psychologists. Methods included questionnaire measures and coding of spoken attributions using the Leeds Attributional Coding System. Non-parametric tests measured between-group differences and correlations between the key variables. There were few differences between the two professional groups for the key variables. Optimism and sympathy were generally associated with willingness to help, and burnout was associated with less willingness to help, low optimism and negative emotional responses to clients' behaviour. No consistent or robust role was found for attributions. The results are discussed in relation to alternative factors, which may promote or reduce staff helping behaviour in the context of services for people with dementia.     

Staff judgements of responsibility for the challenging behaviour of adults with intellectual disabilities

Background This study examines the importance of staff judgements of responsibility for challenging behaviour in predicting their emotional and intended helping responses. Methods Sixty-two carers completed questionnaires rating attributions of internality, stability and controllability, emotions of sympathy and anger, judgements of responsibility for the development of challenging behaviour and for its resolution and intended effort in helping in response to a scenario describing an aggressive behaviour. Results Results showed significant correlations between judgements of responsibility and attributions, emotions and intended effort in helping. Regression analysis showed that the best predictor of intended helping is the emotion of sympathy and that sympathy is best predicted by the attribution of internality, the judgement that people are not responsible for the development of challenging behaviour and the judgement that they are responsible for the resolution of the behaviour. Conclusions Judgements of responsibility predict emotional and intended behavioural responses of carers of people with intellectual disabilities and challenging behaviour. The results are discussed in relation to previous work on carer attributions in response to challenging behaviour. Implications for clinical work with carers are considered.     

Staff responses to behaviour that challenges: The role of knowledge,attributions, and emotion regulation style

Background In this study, we explored the extent to which the knowledge and attributions of support staff predicted their reported helping behaviour in relation to people with an intellectual disability who displayed challenging behaviour (CB), and whether emotion regulation style moderated the relationship between attributions and this helping behaviour.

Method Participants (N = 107) completed self-report measures of knowledge of the meaning and management of CB, causal attributions and behavioural response to CB, and emotion regulation style.

Results Knowledge and helpful attributions were significantly correlated with reported helping behaviour; however, in a regression analysis with both predictors, only knowledge significantly contributed to the variance. No moderating effect was found for emotion regulation styles on the relationship between attributions and reported helping behaviour.

Conclusion Knowledge was the only significant predictor of reported positive staff approaches in managing CB, giving some support for the provision of staff training aimed at increasing knowledge, rather than changing attributions.     

Staff attributions towards men with intellectual disability who have a history of sexual offending and challenging behaviour

Background   Staff working within secure services for people with intellectual disabilities (ID) are likely to work with sexual offenders, but very little attention has been paid to how they think about this sexual offending behaviour.
Method   Forty-eight staff working within secure services for people with ID were recruited and completed the Attribution Style Questionnaire in relation to the sexual offending behaviour and challenging behaviour of men with mild ID. Attributions towards challenging behaviour and sexual offending were compared and relationships between level of ID and seriousness of the sexual offence were explored.
Results   The results indicated that staff attributed sexual offending as more external to the staff group than they did for challenging behaviour. Sexual offending behaviour was also seen as more stable, and less controllable by people with ID than was challenging behaviour. Sexual offending was also attributed as more uncontrollable by the staff group than challenging behaviour. There was a significant negative correlation between general intellectual functioning and several attributional dimensions regarding sexual offending, but not challenging behaviour. Sexual offending that was coded as more serious was attributed as universal and uncontrollable by the staff group.
Conclusions   The differences between staff attributions regarding challenging behaviour and sexual offending potentially relate to the decision-making processes involved in deciding whether or not to involve criminal justice agencies when someone with ID commits a sexual offence. Further research within this area is warranted.     

Care staff attributions about challenging behaviors in adults with intellectual disabilities

A number of researchers have explored the attributions that care staff make about challenging behavior. The expectation, based on behavioral and cognitive models, is that these attributions may help predict why staff inadvertently reinforce challenging behavior. Two studies of staff attributions about challenging behavior are reported. In the first, a high level of consistency in attributions across staff was found. In a second quasi-experimental study, staff made attributions about two known clients' behavior. Analysis of these data showed that attributions varied in a manner broadly consistent with the hypothesized functions of the behaviors. The weight of the evidence suggests that staff may be sensitive to the causes of challenging behavior. The practical implications of these data are discussed.     

The relation between intrapersonal and interpersonal staff behaviour towards clients with ID and challenging behaviour: a validation study of the Staff–Client Interactive Behaviour Inventory

Background   Interpersonal staff behaviour is one of the instigating factors associated with challenging behaviour in clients with intellectual disabilities (ID). There are several studies focusing on the influence of intrapersonal staff characteristics – such as beliefs, attributions and emotional reactions – on staff behaviour. Little is known, however, about interpersonal staff behaviour itself. This study describes the development and validation of the Staff–Client Interactive Behaviour Inventory (SCIBI), measuring both intrapersonal and interpersonal staff behaviour in response to challenging behaviour in clients with ID.
Method   A total of 292 staff members, employed in residential and community services, completed the SCIBI for 34 clients with ID and challenging behaviour.
Results   Confirmatory factor analysis of a seven-factor model – with assertive control, hostile, friendly and support-seeking interpersonal behaviour; proactive thinking; self-reflection; and critical expressed emotion as reliable factors – showed an exact fit to the data, indicating construct validity and reliability of the SCIBI. A series of multilevel regression analyses showed higher age of the client to be negatively associated with assertive control. Job experience, level of education, type and sex of staff predicted interpersonal behaviour. Also, intrapersonal staff behaviour, including critical expressed emotion, proactive thinking and self-reflection, predicted interpersonal behaviour.
Conclusions   The SCIBI can be used to identify staff intrapersonal and interpersonal behaviour towards clients with ID and challenging behaviour. Results obtained with the SCIBI can provide new directions for individual client treatment plans and staff training programmes.     

Staff attributions about challenging behaviours of people with intellectual disabilities and transactional stress process: a qualitative study

Background   Staff explanations about challenging behaviours of people with intellectual disabilities are purported to play a significant role in the way they respond to them. Despite attempts made in research to understand the mechanisms of causality, a lack of association between attributions, emotions and behaviours is reported. This study investigates these relationships within a broader framework including attributions in the transactional stress model of Lazarus and Folkman.
Method   A qualitative design has been selected; semi-structured interview format was used in order to investigate implication of attributions in stress regarding Weiner's model of helping behaviour. A case study method has been adopted to allow consideration of ecological data, a case study representing a special encounter with a challenging behaviour. Categorical analysis was conducted.
Results   The results suggest three main issues. First, it appears that Weiner's model is too restrictive in order to explain the complexity of contextualised encounters. Second, a need to differentiate types of attributions within a temporal perspective is highlighted. Finally, consideration of the coping role of attributions is suggested.
Conclusions   A need to extent the research concerning attribution is suggested. The insertion of research into ecological contexts and the introduction of coping concept regarding staff attributions of challenging behaviours would allow a broader view of the role of attributions.     

The influence of 'cognitive busyness' on causal attributions of challenging behaviour in dementia: A preliminary experimental study

This study investigated the influence of 'cognitive busyness' (competing cognitive demands) on residential care staff attributions of challenging behaviour (CB) related to dementia. Following the model of attribution formation proposed by Gilbert, Pelham, and Krull (1988), it was hypothesised that care staff experiencing competing cognitive demands at the time of observing CBs linked with dementia would be more likely to make internal and controllable attributions regarding the causes of such behaviour. This study employed a cross-over experimental design. Thirty formal dementia care-workers viewed two video clips of simulated CB, one under conditions of cognitive 'busyness' and another under control conditions of no extra cognitive demands. These conditions occurred a week apart and were counterbalanced, i.e. one group of participants undertook the control condition first and then the experimental condition whilst another undertook the reverse. Self-report measures of attributions were administered after the viewing of each video clip. Competing cognitive demands significantly influenced staff attributions regarding CB, in relation to internality and controllability, and type of CB emerged as a potential moderating factor. No link was found between cognitive busyness and other attributional dimensions (stability and globality). Concurrent cognitive demands seem capable of impairing the ability to use situational information to form some causal attributions regarding CB in dementia but this might depend on the type of CB being witnessed. The results are discussed in relation to key methodological and conceptual issues.     

Knowing you: the interpersonal perceptions of staff towards aggressive individuals with mild to moderate intellectual disabilities in situations of conflict

Objectives Staff attributions concerning challenging behaviour have been found to play a role in determining their responses. The emphasis in the literature has been on staff beliefs about the challenging behaviour itself. However, staff are also likely to be responding to the person engaging in the behaviour. The aim of this study was to explore workers’ perceptions of individuals who are frequently aggressive. Design and methods Thirty-six staff members working with individuals presenting problems of frequent aggression participated in this study. They were interviewed about an incident of aggression involving the person they worked with. The semi-structured interview, based on a Rational Emotive Therapy format, aimed to tap into the emotions aroused in the staff members and interpersonal appraisals that they made at the time of the incident. The responses were content analyzed. Results The strength of the staff member's emotional reactions were noteworthy. Furthermore, approximately half of the staff members believed that the clients’ aggression was directed at them personally. In turn, the majority of staff members described their clients in negative terms, and said that their first impulse had been to confront the clients. Conclusions The findings suggest that interpersonal perceptions may have a role in determining staff responses to individuals who behave aggressively. The clinical and theoretical implications of the findings were discussed, alongside directions for future research.     

The relationship among attributions, emotions, and interpersonal styles of staff working with clients with intellectual disabilities and challenging behavior

Several studies have tested Weiner's model, which suggests a relationship among causal attributions regarding challenging behavior (CB), emotions, and helping behavior of staff. No studies have focused on interpersonal styles. The goals of this study were to investigate the influence of type of CB on attributions, emotions and interpersonal style of staff, the relationships among staff attributions, emotions, and interpersonal style, and the mediating function of emotions in the relation between attributions and interpersonal style. Participants were 99 staff members. CB aimed at the environment was related to higher levels of negative emotions, attributions and certain interpersonal styles such as controlling behavior. In addition, a relationship between emotions, attributions, and interpersonal style was found. However, there was no mediating function of emotions in the relationships between attributions and interpersonal style. Future research should take a more dynamic view of staff behavior and staff-client interaction into account.     

Can attribution theory explain carers' propensity to help men with intellectual disabilities who display inappropriate sexual behaviour?

Aim This study examined the responses of care managers and direct care staff to vignettes of inappropriate sexual behaviour by a man with an intellectual disability. The aim was to test the theory that helping behaviour is determined by emotional responses (positive and negative emotional reactions, and optimism), which in turn are determined by causal attributions (respectively: controllability and stability of the incident depicted in the vignette). Method The vignettes varied in response topography and the age of the victim. Regression analysis was used to examine the relationships between causal attributions, emotional responses, and willingness to invest extra time and effort in the service user's care. Results No support was found for the pathway: low controllability → increased sympathy and/or decreased negative emotions → increased helping. However, strong support was found for the pathway: low stability → high optimism → increased helping, particularly in direct care staff. High levels of sympathy were also associated with increased helping, the effect again being mediated by feelings of optimism. Conclusions The data provide support for one (but not the other) strand of attribution theory as applied to inappropriate sexual behaviour. The discussion considers the discrepancy between the present data and the far less encouraging literature on attribution theory as applied to challenging behaviour.     

Staff attributions of the causes of challenging behaviour in children and adults with profound intellectual and multiple disabilities

A study has shown that staff do not generally perceive challenging behaviour in people with profound intellectual and multiple disabilities (PIMD) as being of serious consequence. In this study we aimed to gain a better understanding of the causal explanations that direct care and support staff give for challenging behaviour in this group. The purpose of this study was twofold: (1) to determine the way staff attribute challenging behaviour in children and adults with PIMD; and (2) to analyse whether more experienced staff attribute challenging behaviour in children and adults with PIMD differently than less experienced staff. In total, 195 direct support staff and an equal number of children and adults with PIMD participated in the study. Direct support staff filled out the Challenging behaviour Attribution Scale (five causal explanatory models of challenging behaviour) to explain challenging behaviour in one individual that they supported. The results show that direct support staff as a whole report the biomedical model as the most plausible explanation for challenging behaviour in children and adults with PIMD. However, in the present study the mean scores on all models are low. This might indicate that a large number of staff found none of the models particularly useful as possible explanations of challenging behaviour in people with PIMD. This could mean that staff have difficulties stating the cause of challenging behaviour in this group. Another possible explanation could be that there is little scientific knowledge about causing and maintaining factors of challenging behaviour in people with PIMD. It could also mean that staff have additional explanations for challenging behaviour in this target group that are not mentioned in the instrument used. Future research should address these issues. No differences were found between more experienced and less experienced direct support staff.     

Analysis of staff reports on the frequency of challenging behaviour in people with severe or profound intellectual disabilities

The main goal of this study was to investigate whether staff members vary in their frequency reports on challenging behaviour concerning the same client. Because staff's approaches of challenging behaviour are affected by a range of staff characteristics, we hypothesised that these staff characteristics could explain this variability between staff members. We used questionnaires to investigate the influence of staff's age, gender, experience in working with people with intellectual disabilities, working hours, professional qualifications, sort of education, and their emotional reactions and beliefs regarding the challenging behaviour. This study involved 152 staff members and 51 clients with severe or profound intellectual disabilities who displayed self-injurious behaviour, stereotyped behaviour, and/or aggressive/destructive behaviour. A part of the variability between staff's reports on the frequency of challenging behaviour was indeed explained by differences between the staff members. Working hours, internal attribution, gender, and experience in working with people with severe or profound intellectual disabilities turned out to be influencing variables. Summarising, staff members differ in their reports on the frequency of challenging behaviour. To get an accurate picture of a client's challenging behaviour, perceptions of several staff members are needed.     

Psychological well-being of staff working with people who have challenging behaviour

The present survey explored stress in direct-care staff working with people who have learning disabilities and challenging behaviour. A total of 78 (82.7% response rate) staff working in 14 small community houses participated. Houses were selected on the basis of ‘expert’ (Head of Psychology Services) knowledge of houses where residents were known to display challenging behaviour and houses where there was no known history of challenging behaviour. Residents were assessed by key workers for adaptive behaviour, challenging behaviour and mental health using partially validated questionnaires. Staff completed self-report questionnaires on job demands, anxiety and depression, staff support, and information on the presence/absence of challenging behaviour in their home. Staff working in houses with residents who showed challenging behaviour were significantly more anxious than staff working in houses with no challenging behaviour; they also reported feeling significantly less supported, were less clear about the identification of risk situations and had lower job satisfaction. No differences were found on measures of job demands and depression. Regression analyses exploring the relationships between these variables are discussed along with the implications of the findings.     

Staff factors associated with perception of behaviour as 'challenging' in residential and nursing homes

Three hundred and twenty-six staff, working in 14 residential and nursing homes across England, were asked to rate their 'ease of management' on 14 vignettes of challenging resident behaviour. Multiple regression was used to examine the correlates of staff appraisal of their management of challenging behaviour, using over 30 staff variables. These included demographics, experience, stress, burnout, job satisfaction, knowledge of dementia and management practices in the home. Only staff anxiety, supervisor support and the potential to relate to residents as individuals predicted 'perceived management difficulty'. In any given home, there was great variation in staff perception, and overall, qualified staff appear to have greater difficulty in managing challenging behaviour, as compared with care assistants. The clinical significance of these results for psychogeriatric interventions that focus on advising care staff on the management of resident behaviour is discussed.     

Work stress and people with Down syndrome and dementia

This study aimed to assess how staff ratings of challenging behaviour for people with Down syndrome and dementia affected the self-reported well-being of care staff. Data were collected from 60 care staff in 5 day centres in a large city in England. The data were collected by use of a questionnaire. There was no significant difference between those who cared for individuals with Down syndrome and dementia and those caring for service users with other non-specified learning disabilities without dementia, regarding their self-reported well-being. Self-reported well-being did correlate with staff rating of challenging behaviour in both those who cared for people with Down syndrome and dementia and those who did not care for such service users, with well-being declining as perceived challenging behaviour increased. The findings indicate that challenging behaviour prevention and reduction may be of benefit to both service users and care staff well-being.