Functional Analysis of Behaviour Clinical and Ethical Issues

Discuss the clinical and ethical issues involved in conducting a Functional Analysis of behaviour when working with a client with a learning disability. What evidence is there that this is an effective approach?

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Contents (Jump to)

Introduction

A Holistic approach

The case for employing the functional analysis of behaviour approach

Difficulties with functional analysis

Functional analysis in everyday clinical practice

Case study using functional analysis

Ethical issues relating to the functional analysis approach

Combining different approaches

Conclusion

References

Faced with challenging behaviours shown by people with learning disabilities, the psychologist must decide which analytical approach – behavioural, biophysical, ecological or psychodynamic – will best facilitate appropriate therapeutic interventions.

A number of wide-ranging reviews of the available literature, together with meta-analyses of this area, indicate that interventions based on the behavioural approach offers the most effective way forward. The behavioural approach advocates that all behaviour is learned, and that behaviours are functions of the interplay between an individual and various factors within his/her environment

In his meta-analysis, Didden (1996) concludes that there is “a convincing level of change in terms of reducing challenging behaviour through systematically applied behavioural approaches”, and that behavioural approaches are much more effective than, for example, medication.

The behavioural approaches used to tackle difficult/challenging behaviour fall into three main categories:

^[RZ1]“Differential Reinforcement” involves what is essentially a reward system, whereby an individual is encouraged to exhibit appropriate, rather than challenging, behaviour.

“Gentle Teaching” aims to minimise or eliminate problematic behaviour by creating an environment in which bonding, ; interdependence and mutual respect are paramount, thereby eliminating the need for challenging behaviour.

The teaching of functionally equivalent responses involves firstly a “Functional Analysis” of a particular problematic behaviour, followed by the teaching of more appropriate behaviour, which serves the same function.

When attempting to decide on an appropriate intervention strategy, there is a body of evidence to suggest that the last of these three approaches – the functional analysis – can, if conducted properly, provide an invaluable pointer as to what type of therapeutic intervention might be appropriate.

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This essay will explore the clinical advantages and disadvantages of using a functional analysis of behaviour when working with clients with learning disabilities, examining the research in this area (much of which indicates that this is a generally successful approach) and look at the ethical issues arising from this particular psychological approach.

Definition: Learning Disability

A report from the British Psychological Society (BPS 2004), on Clinical Practice Guidelines for interventions for people with learning disabilities and Severely Challenging Behaviour “states that ,if an individual is to be reasonably regarded as having a “learning disability the individual’s intellectual and adaptive/social functions must both be significantly impaired; and the condition must have existed before the onset of adulthood. An extremely broad-ranging group of learning-disabled individuals fall within these parameters.

Definition: Challenging Behaviour

The following definition by Emerson et al (1988) is widely regarded as a sound working definition:

“Severely challenging behaviour refers to behaviour 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 or delay access to and use of ordinary community facilities.”

The nature of the “challenging behaviour” (the causes and functions of which can be many and diverse) itself has been described as “behaviour which: places the individual or others in physical danger; results in destruction of their immediate environment; causes at least an hour’s disruption; or behaviour which limits or delays access to ordinary community facilities” (Scottish Office, 1998).

Challenging behaviours may involve verbal or physical aggression, self-harm behaviour, and other non-injurious (but nevertheless undesirable) behaviours.

Challenging behaviour is generally understood to be triggered by the interaction between variables within individuals themselves (mood, health, etc.) and variables within their social and physical environment.^[RZ2]

Functional analysis are comprises various methods, all with the aim of establishing the link between antecedents, behaviour and its consequences. (Kazdin,1994)

More specifically, functional analysis are is a tools to reveal reinforcing conditions^[RZ4]?????, – I am translating from Norwegian)..established operations and triggers for problem behaviour. (Vold, 2005)

This information is then used for customizing interventions and treatment for the person in question.

This definition includes all systematic methods that examine the root cause(s) of a certain behaviour. These methods include interviews and standardised tools like MAS (Durand, 1990) and FAI (O’Neill et al, 1997), different methods of observations of the person in his/hers environment, likce “scatter plot” (Touchette et al, 1985) and ABC charts ( antecedent-behaviour-consequence ) charts. (Bijou et al, 1968)

In addition, we there arehave the experimental methods, also called analogue conditions. These methods consists of the a systematiccally testing and manipulation of events (or other factors^[RZ5]), which are thought to be associated with the occurrence of problem behavior. It is therefore a means of formally examining the relationship between specific events and the particular problematic/challenging behaviors of an individual in a specific environment. (Iawata, et al, ,1982)

These methods complement each other, but by using one – or a combination of them —– the “functional analyst” aims to have a much clearer idea of the triggers of, and the purposes served by, a specific behaviour.

It should also be pointed out that functional analysis can be used in either a clinical application or as a valuable research method (Vollmer and Smith, 1996). Furthermore, Vollmer and Smith concluded that functional analysis could be used to identify individuals with the specific behavioural functions^[RZ6] required enabling psychologists to pursue specific avenues of research (while bearing in mind that functional analysis does not always yield conclusive results).

Rather than simply looking at the functional analysis as a means of dealing with challenging behaviours, Groden and LeVasseur 111posit a more holistic approach, which takes into account “the dynamic relationship between the individual, his or her skills and the environment, including the stressors, in which the behaviour occurs.”

A behavioural assessment method, which has stood the test of timeme, is detailed in Groden et al (1996).^[RZ7] Using this method, the behavioural assessment data for each individual is obtained from a number of sources. The procedure not only involves including a functional analysis of the target behaviour, but also an ecological inventory, a Stress Survey Schedule, and reinforcement surveys.

The information is then placed in an illustrated A-B-C format, with each illustration designed to match the individual’s intellectual abilities and reinforcers. It depicts the preferred mode of behaviour, which the person with a learning disability can use in a specific problematic scenario.

In the early years of the use of the functional analysis by psychologists working with people with learning disabilities who exhibited challenging behaviour, four key functions were identified: attentionattention- seeking, escape (task or social avoidance),; sensory reinforcement, and tangible events (Carr, 1994).

Functional analysis can uncover new functional properties of problem behaviour, but it is also necessary to develop additional strategies to address the complexities of an individual’s normal (i.e. non-experimental) environment.

One such approach is the hypothesis-driven model developed by Repp et al (1988), which is based on both direct observation and the analysis of antecedent and consequent events.

In the seminal paper “Psychological interventions for severely challenging behaviours shown by people with learning disabilities – Clinical Practice Guidelines”, the British Psychological Society established step-by-step “gold standard” guidelines for those who wish to employ the functional analysis of behaviour approach. (BPS, 2004)

Having gained the appropriate consent^[RZ8], the process should commence with the Pre-assessment, (a term first employed by Toogood and Timlin (1996)), at which stage the psychologist engages in initial information gathering, with a view to honing the initial focus of the psychological assessment.

At the Assessment stage, the assessor collects and then evaluates all appropriate information about the person with a learning disability, the environment (both social and physical) and the challenging behaviour exhibited by the individual. These steps should enable the psychologist to collect the information required to create a well-structured psychological assessment and an appropriate intervention strategy, and to establish a baseline, which will enable the psychologist to measure the success of any intervention.

At the Formulation stage, the psychologist draws up a hypothesis about the nature of the specific behavioural problem(s), thereby providing a guide to subsequent clinical activity as well as establishing key evaluation criteria. It will also specify the target of any intervention.

At the Intervention stage, the psychologist will endeavour to change the individual’s problematic behaviour in an appropriate manner, utilising both technical psychological expertise as well asnd the detailed information previously accumulated about the individual and his/her environment.

At the Evaluation stage, the success/effectiveness of the intervention(s) will be weighed up and carefully considered.

The process is finalised at the self-explanatory Feedback stage (from and to all interested parties, first and foremost the person with a learning disability).

In the course of their study, Vollmer and Smith (1996) concluded that functional analysis has its limitations. Most importantly, some interventions derived from functional analysis can be difficult to carry out while still maintaining non-intrusive procedural integrity.

Martin et al (1999) demonstrated that there can be problems in interpreting the data arising from functional analysis in an experimental context.

For the purposes of their study, the validity of a functional analysis was investigated using three different data-interpretation methodologies (two previously utilised methods, and “criterion Z” created by the authors). They ultimately concluded that all three methods were equally unsatisfactory as a way of establishing the function of a particular behaviour. ^[RZ9]

It should also be remembered (Freeman, Special Connections website).

that challenging behaviour does not always have a specific function. It is possible,; instead, that “internal sensory feedback” is responsible for triggering an individual’s challenging behaviour. Such behaviours tend to occur when the person with a learning disability is alone, or arise in many quite different and contrasting social scenarios, and may be the result of internal, rather than external, reinforcers.^[RZ10]

Lack of agreement about function across different methods

After carrying out a thorough functional analysis, a psychologist (or other practitioner) should be in a position to identify the cause-effect relationship between an environmental “trigger” and a specific behaviour. However, different approaches to functional analysis appear to give conflicting results.

Toogood and Timlin (1996) looked at the three approaches to functional analysis described above and found a low level of agreement between each of the different approaches in relation to their understanding of the target behaviours’ functions.

The importance of identifying idiosyncratic variables

A very wide range of stimuli can trigger challenging behaviour. Because a wide range of unanticipated variables can come into play, certain some of which may appear to be apparently insignificant, but which are in factin fact key, these variables can may be overlooked during the initial assessment, thereby giving rise to misleading results. An important study by Carr et al (1997) underlined the necessity of identifying specific “idiosyncratic” (or unanticipated) variables.

In this particular study, each of the three clients was autistic (and regarded, broadly speaking, as learning disabled) and had exhibited problem behaviours such as aggression, self-harm and vandalism. Interviews and direct observations indicated that these challenging behaviours might serve the functions of attention gaininggaining attention or escape.

On subsequent and closer examination using Carr’s ABC, narrative protocol, however, it became apparent that specific “idiosyncratic” stimulus variables (or the absence thereof) had a major influence on the results of the functional analysis. In the final stage of the study, the specific idiosyncratic stimulus variables which had been observed in a naturalistic environmental context (small hand-held objects,

and the presence of puzzles/magazines in the room) were manipulated^[RZ11] in an experimental context (a room with a two-way mirror that facilitated the video-taping of the proceedings) with a view to establishing their effect on the outcome of the functional analysis.

While this study generally endorsed the usefulness of the functional analysis approach, it underlined the importance of meticulous attention to detail to ensure the accurate identification of behavioural-stimulus variables which that were not immediately obvious. Failure to do so would have significantly altered the outcomes of functional analyses.

The authors concluded that that tailored guidelines should be in place when it is suspected (because there is a discrepancy between information arising from interviews and actual observed behaviours; when different results occur in different locations; or if the results differ from day to day) that idiosyncratic stimuli may be significant triggers for the behaviours being studied, e.g. .because there is a discrepancy between information arising from interviews and actual observed behaviours, or when different results occur in different locations, or if the results differ from day to day.

Taking into account the above-described difficulties, together with the fact that a thorough functional analysis is time– consuming,. pPsychologists in everyday clinical work are faced with a number of challenges.

Some of these are of ethical nature and will be discussed later, whilst others are more practical issues.

It follows from the initial definition of functional analysis used in this essay that the term is applied for different procedures, each presenting both the practitioner and the client with different challenges and benefits.

In addressing the fact that time limitations can often compromise attempts

to complete a thorough functional analysis in its more experimental design, Wallace and Iwata (1999) examined the extent to which variations in session duration (5,10five, ten, and & 15 minutes) affected the outcome of a functional analysis. Their findings led to the conclusion that brief sessions did not give less clarity than longer sessions.

An important study by Derby et al (1992) provided a analysis of the success of brief functional analysis. This study presents a summary of the results of 79 cases which used functional assessment procedures in order to determine how often the brief functional assessment successfully identified the triggers of aberrant behaviour, and whether the treatments based on the assessment were effective.

Given that only 90 minutes were generally allocated to outpatient evaluations in the instructions of interest to the authors, Derby et al adapted the functional analysis procedures described by Carr and Durand (1985) accordingly. They went on to publish a report summarising the results of 79 cases in an effort to establish whether functional assessments correctly identified the “specific maintaining conditions of aberrant behaviour”,” and if subsequent treatments were effective.

In each of the 79 studies, clients were, under pre-specified conditions, evaluated by direct observation of behaviour.

Of the 63% of the cases studied in which functional analysis correctly identified the function of aberrant behaviour, 77% resulted in effective treatment. This finding suggests that the abbreviated 90-minute functional assessment can in many cases successfully lead to successful treatments. These “short-cuts” should not, however, entirely replace the full-scale, thoroughly researched, non time-limited functional analysis, but can be viewed as a viable “second best” alternative when available time is limited.

It should be noted that tThe ecological validity of functional analysis methodology has been questioned (Martin et al, 1999) as the assessments take place outside the natural environment where the problematic behaviour usually takes place.

When relying upon informant-based and/or descriptive methods, other problems arise, and psychologists need to ask themselves questions about the informants’ capacities to record observations without traces of interpretation. For example, tThe fact that clients are being observed may well influence their behaviour and invalidate results.

In an inpatient setting, the mere presence of an observer may change the ecological environment, which will affect all the clients’ behaviour, and the antecedents and/or triggers for the target behaviour will be increased or decreased, and the data may be invalidated.

Carr and Durand (1985) have provided evidence that the functional analysis approach can give rise to effective intervention strategies. They posit that, broadly speaking, “challenging behaviour fulfils four main functions :

These are (a) a means of gaining attention (b) an ‘“escape from demands’”

(c) a ‘“tangible reinforcement’” and (d) a means of obtaining “sensory stimulation”.

A form foofr self– injuring behaviour —, for instance, head– banging —, may well fit into one or more of these functions.. But the head– banging doesn’t fails to tell us whether the person is doing it because of frustration, hallucinations, anger or a middle ear infection.^[RZ12]

It is widely recognised that people with learning disabilities often have limited verbal communication ability. Many may therefore rely on non-verbal means of expressing themselves, especially in regards to communicating emotions. As a whole, people with learning disability are more prone to suffer from mental illness, personality disorders, anxiety and depression than the rest of the population.

But whatever function the challenging behaviour fulfils, it can be seen as a form of learned communication that previously has fulfilled the needs of the person with a learning disability.

A person with a learning disability who gains a caregiver’s undivided attention (even if the caregiverr is angry or irritated) more readily by shouting than by talking politely will tend to conclude that the most efficient and effective way to get the carer’s attention is to engage in the aforementioned challenging behaviour. A self-injury by a person with a learning disability may result in a show of gratifying concern from a carer. This “positive” outcome may lead to repetition of the self-injurious behaviour. One or more problem behaviours can, in certain circumstances, serve the same function, and can occur in a chain of escalating seriousness (e.g. minor fiddling with a small object leading on to the violent hurling of a larger object, minor complaints leading to vicious abuse). Awareness of this can enable a caregiverr to intervene early in the “chain,”, thus minimising negative consequences (i.e. events which come directly after an instance of problematic behaviour (Albin et al, 1995).

Caregivers should be careful not to simply assume that a consequence is regarded as a “punishment”, and should consider whether the supposed punishment decreases or in fact increases the undesirable behaviour. For example, iIn a setting such as a hospital for people with learning disabilities detained under the Mental Health Act, for example, consequences such as restraint or even seclusion may actually be increaseing the incidence of challenging behaviour, as the behaviour in question can provide a means of gratification. The following case study shows how a functional analysis was useful to show the likely presence of these factors at play with a woman with a learning disability detained under the Mental Health Act in a medium secure unit.

Case study:

The 25– year old woman had a dual diagnosis of learning disability and a mental illness.^[RZ13] She was admitted to a mixed gender ward with both male and female staff. She was a very big and strong lady and her challenging behaviour, which took the form of attacks for no apparent reason, posed a threat both to staff and fellow patients.

Prior to herBy admission, a pre – assessment and initial risk assessment had been carried out. This was followed up by an initial assessment, carried out by nursing staff who recorded theing frequency and severity of her challenging behaviour in an ABC chart, as well as monitoreding activities and situations the patient she seemed to enjoy. Her mental health symptoms were treated with the recommended drugs.

The data collected showed up to four weeks without challenging behaviour that wasn’t easily deflated. On At occasion (during a one-to-two week period)s she could, however, during a one to two weeks period, display behaviour that at least once a day lead to necessary restraint by staff.

The intervention put in place included allocation of a specific health care worker that would initiate activities that the patient she liked doing and instruction to staff to redirect her when she was becoming restless.

Due to her lack of communication skills, key staff was trained in specific ways of communicating with her.

After approximately six6 months there was a marked increased frequency in the incidents of challenging behavior as well as in the duration and violence involved. . Although the patient’sher communication skills had improved and her daily activities had been refined to suit her strengths and interests, her attacks became so viciously that seclusion became an unfortunate necessity at least three times a month, usually within the same week. As no new antecedents were detected, a functional analysis was carried out , which included the three main methods, was carried out:

Nursing staff continued to observe her the patient continuously and filled in ABC charts. Records were taken of her sleeping pattern, food and drink intake and menstrual cycle (informant-based method).

Any changes in the ward were recorded, i.e. new admissions, staff leaving and new staff appointed. Assistant psychologists observed her on the ward and recorded behaviour on during 5 five-minute s intervals (direct observation). The clinical psychologist, who also had participated in observations, analysed the data and drew up a hypothesis about the nature of the increased challenging behaviour. On this basis of this, variables in the patient’s environment were, one at athe time, changed and tested (experimental method).

The data collection demonstrated that the incidents of challenging behaviour peaked at a certain time in her menstrual period, indicating a hormonal factor. This factor alone was not conclusive enough on its own to account for her behaviour. It was treated as a setting factor that increased the probability of incidents, when short-term triggers were also present.

The observations also carried out highlighted that when restraint was necessary, male staff carried it out, due to the patient’s size and strength, mainly did this. When there wereith only female staff working inon the ward, there was a significant reduction in her attacks, provided that she was being kept occupied by staff to avoid boredom.

The policy and procedures for seclusion made it mandatory for staff to remove clothing that she might use to hurt herself with. Although female staff always carried out removal of clothing, she was still being placed in restraints by male staff. Direct observations and staff reports suggested that the presence of male staff during this process escalated her behaviour.

Most importantly, however, was the correlation between her challenging behaviour and the presence of a specific male member of the staff. Nursing reports showed that when he was off duty, the client’s challenging behaviour never reached the level when seclusion was necessary. Furthermore, observations showed that she was always happy to greet this member of staffstaff member when he arrived for work, and she frequently sought him out for help or company.^[RZ14].

The interventions implemented were to move the male member of staffstaff member to another ward for a period of time and to stop male staff participation intervention in the restraint processrestraints. Guidelines were implemented to ensure that the patient she was dressed in clothes she could safely wear if seclusion was necessary. The cA contraceptive pill was prescribed in order to keep her hormone level in balance, and a program with intermittent positive reinforcement was developed to re-introduce a certain interaction with male staff.^[RZ15]

The intervention was successful insofar that heras the patient’s challenging behaviour decreased. It demonstrates the effectiveness of a functional analysis as well as the danger of interventions become too intrusive. But it also, it highlights many of the ethical challenges a practitioner might face when working with people with learning disability and challenging behaviour.^[RZ16]

Given that the vast majority of individuals with learning disabilities are highly vulnerable to abuse, neglect and exploitation, it is vital that an “ethical framework” exists, within which practitioners can operate when using the functional analysis approach. The practitioner must also ensure the following: that he/she operates within the law of the land at all times; the practitioner must endeavour to operate within the parameters imposed by the relevant professional association’s’ Code of Practice; must adhere to local standards and policies (e.g. those set by a particular Trust); and must operate (as far as possible, given the previous strictures) within his/her own personal set of ethics and principles.

Consent

As with any other assessment or intervention, the client or service-user must give his or her consent. People with learning disabilities encompass a broad range of abilities. Some will understand the implications of assessments and interventions and will be able to give their consent, whilst others are unable to do so. The latter group may have guardians to provide consent on their behalf. But most lay people tend to accept without much questioning that “the professionals know best.” . It is the