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 BOOK REVIEWS

Challenging Behaviour. Third Edition

Richard Balon, MD

Wayne State University, Detroit, MI, USA

By Eric Emerson and Stewart L. Einfeld. Cambridge University Press; New York, NY; 2011; ISBN 978-0-521-728935; pp 228; $67 (paperback).

“Challenging behavior” is a term that has replaced terms such as abnormal, aberrant, disordered, dysfunctional, maladaptive, or problem behavior (p 3). These terms previously have been used to describe behaviors—eg, aggression, destructiveness, self-injury, stereotyped mannerism—shown by people with severe intellectual disabilities (p 3-4). These behaviors, as, Eric Emerson and Stewart Einfeld, the Australian authors of this slender volume, point out, “may be either harmful to the individual (eg, eating inedible objects), challenging for carers and care staff (eg, non-compliance, persistent screaming, disturbed sleep patterns, overactivity) and/or objectionable to members of the public (eg, regurgitation of food, smearing of feces over the body)” (p 4). Many psychiatrists have faced such behaviors during their career; those working in state hospitals or other long-term facilities (eg, facilities for the intellectually disabled) have faced these behaviors more frequently, if not daily. It is important to note that challenging behavior is not synonymous with any psychiatric diagnosis (p 4), although it occurs more frequently in patients with intellectual disabilities (approximately 0.1% of people have a severe intellectual disability and also engage in challenging behaviors [p 1]). We do not understand these behaviors and do not know much about them, yet we are supposed to manage them or at least guide others on how to manage them. The authors of this book put together what has been learned about the nature of these behaviors and what approaches have been developed to bring “rapid and socially significant reductions in challenging behavior” (p 1). However, this is not a “how-to-do-it” book; it is a summary of present day knowledge with some implications for clinical practice (p 1).

The book consists of 13 chapters and could be considered as having 2 sections—one (the first 8 chapters) summarizing our current understanding of challenging behaviors and one (5 chapters) focusing “on the design and implementation of interventions and supports for people with severe intellectual disability and challenging behaviours” (p 6). The first chapter serves as the introduction to the volume, providing terms and definitions of intellectual disability and challenging behaviors followed by a brief overview of the book. The discussion of intellectual disability points out there are 2 distinct groups of patients with intellectual disability—those representing the lower end of the normal distribution of intelligence in the population and those whose cognitive impairment is the result of “identifiable or apparent disorders of genetic or environmental origin” (p 3) (the latter being usually more severely impaired). The second chapter, “The social context of challenging behaviour,” emphasizes that challenging behavior is a social construct depending on social rules regarding what constitutes appropriate behavior in that setting, ability of the person to give plausible account for their behavior, the beliefs held by others in the setting about the nature of intellectual disability, and the causes of challenging behavior, and capacity within the setting to manage any social disruption caused by this behavior (p 7). The chapter also discusses the negative personal and social impact of challenging behaviors, such as abuse, inappropriate treatment, social exclusion, deprivation, and systematic neglect. The last part of this chapter focuses a bit prematurely on intervention outcomes. The third chapter, ‘The epidemiology of challenging behaviour,” reviews the prevalence of challenging behavior (1.91/10,000 of the general population were identified as having an intellectual disability and serious challenging behavior, which translates to approximately 6% of people with an intellectual disability), types of challenging behavior, co-occurrence of challenging behaviors, personal and environmental risk factors (male sex, age, various disorders, setting), and the natural history of challenging behaviors. The next chapter, “Biological influences,” points out “behavioural and neurobiological/psychiatric traditions have dominated applied research within the field of intellectual disabilities” (p 25). The chapter discusses common genetic causes of intellectual disability that increase vulnerability to challenging behaviors (behavior phenotypes of different disorders), psychiatric disorders that manifest or are associated with challenging behaviors (eg, autism, psychosis, mood disorders), and the role of conditions such as pain, epilepsy, side effects of psychotropic medications, and temperament in challenging behaviors. Interestingly, there’s no discussion of substance abuse. Chapter 5, “Behavioural models: the functional significance of challenging behaviour,” focuses on applied behavioral analysis of these behaviors and issues such as functional relationship, contextual control, positive and negative reinforcement, and automatic reinforcement. This is probably the least readable chapter of this volume. Chapter 6, “Broader environmental influences on challenging behaviour,” in its discussion of socio-economic position, poverty, and behavioral difficulties stresses that there is a wealth of evidence documenting the negative impact of exposure to low socioeconomic position and/or poverty on general behavioral health and well-being in the general population (p 54). Another less informative chapter, chapter 7, “Making connections,” tries to synthesize the possible biological, behavioral, and environmental influences on the emergence and persistence of challenging behavior. Finally, the brief chapter 8, “The bases of intervention,” addresses general characteristics of current “best practice” in approaches to supporting people with intellectual disabilities and challenging behavior (p 67).

The second section, focusing on design and implementation of interventions, starts with a chapter on assessment and formulation. A useful part of this chapter is a review of scales used to evaluate challenging behavior, together with observational methods used in descriptive analyses of challenging behaviors in applied setting (ABC charts, scatter plots and related techniques, sequential analysis). The chapter includes a useful table summarizing the descriptive and experimental approaches to functional assessment of challenging behaviors, and a good suggestion of assessing existing skills, competencies, and potential reinforcers. The following chapter, “Pharmacotherapy,” notes that physicians frequently are pressured to prescribe medication to diminish or contain challenging behaviors (p 94) and warns of many potential side effects of psychotropics. The chapter also outlines general guidelines for pharmacotherapy (comprehensive assessment; informed consent; pharmacotherapy being an integral part of other concurrent treatments; reliable and valid documentation—documentation that target symptoms had a positive response; attempts to reduce medication; proper withdrawal regime; etc.). The chapter finally reviews the effectiveness of medications and approaches (antipsychotics, antidepressants, electroconvulsive therapy, anxiolytics, mood stabilizers, stimulants, anticonvulsants, antilibidinal agents, and opioid antagonists). Chapter 11, “Behavioural approaches,” deals with behavioral approaches based on manipulating antecedent stimuli or changing the context to prevent occurrence of challenging behavior; behavioral competition or response covariation; disruption of maintaining contingencies; and punishment or other “default” technologies (p 102). The chapter presents an interesting notion that decreases in challenging behavior may be brought about indirectly through increasing the rate of other behaviors. A table summarizing behavioral approaches to intervention is useful because it includes advantages and disadvantages of approaches. Chapter 12, “The situational management of challenging behaviour” (written by David Allen, Cardiff University, Cardiff, United Kingdom) proposes that “situational management strategies are a necessary component of comprehensive intervention for many individuals with intellectual disabilities and challenging behavior” (p 129). The chapter includes a solid table summarizing the typology of situational management strategies (from active listening to medication) and also presents an overview of good practices in situational management. Last but not least, the text suggests reducing the use of situational management and how to do it. The final chapter, “Challenges ahead: adopting an evidence-based public health approach to challenging behaviour,” points out that we have amassed an impressive body of evidence on the short-term efficacy of behavioral interventions (p 144). The chapter suggests a public health approach to challenging behaviors within the framework of prevention (primary, secondary, and tertiary). In their final thoughts, the authors muse about the fact that “all of the evidence cited in this book has been generated within the world’s richer countries (and primarily within the world’s richer English-speaking countries)” (p 159) although most people live in low- and middle-income countries. They suggest that, “the key issues in scaling up service delivery in low and middle income countries include the development of low-cost and culturally sensitive procedures for identifying people with intellectual disabilities, and extending the reach and effectiveness of community-based rehabilitation and family-centred [sic] support to people with intellectual disabilities and families who support them” (p 159).

This is a good, well-written small book. The fact that it is authored and not edited by 2 experts certainly helps with readability and flow. Most chapters are informative, only a couple of them are a bit too abstract and wordy. This text will be useful to all psychiatrists who routinely deal with challenging behaviors, either in inpatient units or in facilities for people with intellectual disabilities.