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4.9.3 The Management of Children with Challenging Behaviour

SCOPE OF THIS CHAPTER

This chapter sets out the current policy, procedure and guidance for staff and foster carers in the management of children with challenging behaviour. 

This chapter is due to be reviewed during 2009.

For additional information see Physical Intervention Procedure


Contents

  1. Introduction
  2. Definitions
  3. Statutory Framework and Procedures
  4. Child Care Policy and Guidance on the Management of Challenging Behaviour
  5. The Use of Physical Intervention in Managing Challenging Behaviour
  6. What is Reasonable Force?
  7. Staff Safety and Training
  8. Key Issues to Consider Before using Physical Interventions
  9. Strategies to Manage Behaviour
  10. Debriefing with the Child Following an Incident
  11. Debriefing Staff/Carers following an Incident
  12. Assessing Risk and Behaviour Management Plans
  13. Medical Advice
  14. Holding Children
  15. Review and Monitoring
  16. Complaints
  17. In Conclusion


1. Introduction

1.1

This Policy document relates to the management of challenging behaviour exhibited by children who receive care provided solely by Bexley Council or in conjunction with Social Policy Management Services (SPMS). 

This document aims to achieve the following;-

  1. To provide a framework for the provision of the best possible care practices for children looked after which is clear, explicit, and accessible.
  2. To provide guidance for carers and staff within Children's and Young People's  Services and SPMS working with children who may present challenging behaviours.
1.2 This document is broadly written and local procedures to implement this document need to be agreed within each team/service area.  The strategies adopted may require a different approach depending upon whether it is a team seeking to manage challenging behaviour within a duty setting, or a Centre managing challenging behaviour with other carers, children and young people present, or a foster carer managing challenging behaviour in isolation in their home.
1.3 It appreciated this document is lengthy and comprehensive.  A conclusion and two flowcharts have therefore been included at the end of the text for ease of reference.


2. Definitions

"Carer"  - this is any person providing care for a child or young person on behalf of Bexley Council or SPMS, this includes foster carers, residential social workers, social workers and resource centre workers.  Agency/Bank workers are included in so far as they will be required to implement Behaviour Management Plans, but cannot use physical restraint without undertaking the Council's authorised restraint training.

For the avoidance of doubt, other professionals providing services for young people e.g. health personnel at Falconwood, are not covered by this policy.  They will be covered by the policies and procedures of their own employers.

"Risk Assessment" - The full consideration of a child's behaviours that are perceived by a person, or persons having responsibility for the care of that child, may result in serious physical or emotional harm to a child, carer or other person.

"Challenging Behaviour" - "Behaviour of such 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."  Emerson (et al 1987). 

This policy document does not relate to:

  • the management of behaviour that would be termed "naughty" behaviour. 
  • using physical intervention for urgent or routine medical interventions (if a child refuses medication, advice must be sought from a medical advisor).
  • the use of drugs/medication to manage behaviour.  Medication is only given under the direction of a doctor.

"Restricting Liberty" - s.25(1) Children Act 1989 relates to the use of secure accommodation for restricting liberty.  The criteria that has to be met before a child or young person can be placed in secure accommodation is very strict.  The relevant elements of the criteria shall be taken as the baseline applied by carers before restricting the liberty of a young person in their care:

  1. if she/he absconds, she/he is likely to suffer significant harm; or
  2. if she/he does not have her/his liberty restricted she/he is likely to injure her/himself or other persons.

"Significant Harm" - For the purposes of this policy it will mean behaviour that has the potential to lead to serious physical or emotional harm. 

"Behaviour Management Plan " - ("BMP") a plan that records information and guidance for carers, detailing how challenging behaviour might be avoided and strategies to manage it should an incident arise.  It is drawn up in collaboration with the child's social worker and all those responsible for arranging and providing direct care for the child.


3. Statutory Framework and Procedures

This Policy is underpinned by the following statutory framework and procedures.

  • Draft Operational Policy of Falconwood
  • The Children Act 1989 Guidance and Regulation, Volume 4 paragraphs 1.82 - 1.91. (Regulation 8 (2))
  • The Children's Homes Regulations 1991. (Section 8)
  • "The Permissible Forms of Control in Children's Residential Care" Guidance from The Department of Health (April 1993)
  • Management of Aggression and Challenging behaviour Learning Disabilities Service Issued September 1995
  • DfEE Circular 10/98...."The Use of Force to Control and Restrain Pupils"
  • The National Care Standards Commission (Registration) Regulations 2001
  • Children's Homes Regulations 2001


4. Child Care Policy and Guidance on the Management of Challenging Behaviour

4.1 This policy is intended to reflect the highest standards of care and be consistent with best professional practice and the values and principles promoted by The Children Act 1989. It should be read in the context that those professionals managing children with challenging behaviours have an understanding of why the behaviours may be occurring. It used to be thought that behaviour was intrinsic to the individual, but it is now thought that challenging behaviour is influenced by, or is the result of, environmental, physiological or psychological factors. However, there is a responsibility upon carers to work with unacceptable behaviour constructively, and sensitively, to help children develop socially.
4.2 Bexley Council's Child Care Policy provides the overarching policy framework which underpins this policy. 
4.3 Whilst under the age of 18 years, irrespective of whether a child is subject to a Care Order or s.20 accommodation, parents and other adults who have parental responsibility retain this and will be consulted about all relevant care management arrangements. This will include any arrangements or measures that may be used should the child present challenging behaviours. 


5. The Use of Physical Intervention in Managing Challenging Behaviour

5.1 At certain times incidents will occur where there is a direct risk of harm to a child, carer or another person.  The Department of Health makes it clear that any action which is taken to restrict a child's liberty (including freedom of movement) should be limited to circumstances where immediate action is necessary to prevent injury to any person, or damage to property.  In some circumstances "property" can include harm to animals. This policy confirms that where immediate physical intervention is necessary to prevent harm to a child, carer or another person, such action should be limited to the minimum required, and for the minimum time necessary to prevent the identified harm. 
5.2 Physical interventions should never be used as a threat, aversion, to force       compliance or as a punishment.
5.3 This policy does not support the use of physical restraint including physical intervention for the specific purpose of avoiding damage to property, alone. However, it must be remembered that in damaging property individuals, including the child, may be injured inadvertently e.g. by flying glass. 
5.4 Force or physical interventions should only be used as a last resort in most cases and should be seen as only one option in the range available to manage behaviour.  Other techniques designed to avert or defuse a situation should be applied in the first instance wherever possible.  Knowledge of a range of behaviour management strategies is therefore crucial to those working with children with behavioural problems.
5.5 Carers who find themselves in a position where they are compelled to use physical interventions, must be mindful of the child's sensitivities and sensibilities, their likely perceptions of situations, their emotional state and their levels of understanding. Different approaches may be needed for children of different ages, gender, levels of physical development, physical disability, and the characteristics of their special educational needs.  Previous life experiences may also have a bearing on an appropriate response e.g.  a child who has suffered abuse may be traumatised by being held in certain positions, or by being taken to their bedroom.
5.6 Carers, especially if they are alone with a young person, are not expected to put themselves at undue risk.  If for example an adolescent is demonstrating escalating aggression that, in the view of the carer, is likely to lead to harm to themselves or others, it may be more appropriate to allow the young person to leave the premises to give them time to calm down.  It may then be necessary to either instigate the procedures for a missing person, or to alert the child's social worker depending upon the circumstances e.g. the time of day, the age of the child and their history.


6. What is Reasonable Force?

6.1 The use of force will only be lawful if the circumstances of a particular incident warrant it.  If the particular circumstances do not warrant its use, the intervention will be unlawful.  The degree of force used must be in proportion to the circumstances of the incident and the seriousness of the behaviour or the consequences it is intended to prevent. For example, the use of physical restraint to prevent minor damage to property will not be reasonable. Any force used must be the minimum needed to achieve the desired outcome.  Case law indicates that Courts will expect a person to retreat rather than use force if this is possible. In the case of managing children however, this may not be a safe option.  Carers involved in the management of aggression must be guided by the principle of acting in good faith in accordance with their duty of care to children for whom they are responsible.
6.2 Physical intervention that amounts to corporal punishment is unlawful and must never be used.
6.3 It is acknowledged that individuals will use their own judgement as to the acceptability of behaviours and that some people will have a greater threshold in terms of behaviours they are able to cope with.  It is not therefore possible to give definitive thresholds as to when physical interventions can be used.  Under this policy all incidents have to be fully recorded, and close monitoring of all reported incidents will enable the department to determine whether individuals are using physical interventions inappropriately.


7. Staff Safety and Training

7.1 All carers working with children where challenging behaviour is an issue will receive training to ensure they are conversant with, and understand the content of this       document, and their responsibilities within it.  For the avoidance of doubt, that includes agency/bank staff.
7.2 Carers need to be mindful of their own safety, and the safety of other children in their care. It is therefore essential that carers using restraint techniques have undergone the prescribed restraint training agreed by Bexley Council and SPMS. Training courses will be offered to carers on a regular basis to ensure new carers joining the service are able to respond to behaviours using approved techniques. Such training will have taught them how to employ calming interventions designed to avoid conflict, and support and reassurance for the young person during and after episodes of physical contact. Carers will also receive guidance from appropriate supervisory staff regarding Behaviour Management Plans (BMP's). This will include consideration of the need for staff learning and the appropriateness of a programme of learning or special support for the child concerned. Training needs will be identified and recorded annually for each carer.  This will be in the prescribed form appropriate to their role e.g. Personal Development Plan for Bexley Council employees and the annual review for foster carers. 
7.3 The likelihood of challenging behaviour occurring is generally reduced in a positive environment where children feel accepted, settled and stable.  If a child has a positive care experience, constructive relationships are more likely to develop. Children who experience changes of carer will naturally be anxious. Away from their familiar setting, they may be unclear about what is expected of them and they may have less of a sense of investment in their surroundings.  Carers will be pro-active in seeking to address this both through activities specifically designed to reduce anxiety, and to enable children to feel at ease, as a normal part of their day-to-day work of providing care. Managing challenging behaviour should not therefore be viewed in isolation but should form part of developing a consistent, respectful approach to all young people.
7.4 It is recommended that all carers attend Bexley Council or SPMS approved First Aid training.


8. Key Issues to Consider before using Physical Interventions

8.1 The child's BMP must set out strategies that can be adopted with each specific child to manage behaviours effectively.  The use of physical interventions must not be seen as an easy option and must be a last resort.  Interventions can be described as being on a continuum, and it must be decided as part of the BMP in what circumstances the intervention will move through this continuum.  Physical interventions are always at the top end of the continuum.
8.2 The circumstances in which a physical intervention might be appropriate can include those where it is imperative on the grounds of safety that a child complies with an instruction e.g. to leave a building when a fire alarm is sounding, or to stop hitting another child.
8.2 In most cases carers should give a child a clear direction as to what behaviour needs to be tempered/stopped, coupled with a warning, before using a physical intervention.  This may not always be possible with children who have a severe learning disability.
8.3 Whilst this will not always be possible, especially for foster carers, if a physical intervention is used, a carer should always try to have a witness present.


9. Strategies to Manage Behaviour

9.1

There is a continuum of interventions that can satisfactorily manage challenging behaviours.  Strategies to avert or deflect a child or young person are at the lower end and include allowing a child space or humouring her/him.

Physical interventions are at the top end of the continuum.  They can include blocking a child's path or "holding" using prescribed methods.
9.2 It is not reasonable force for carers to hold a child around the neck, or by the collar, or in any other way that might restrict the child's ability to breathe for example.
9.3 It may be necessary on occasions for carers to call the Police if they are of the view that a situation cannot be resolved safely, or contained by them alone, and that either their safety or that of the young person, or other young people in their care is seriously compromised.  If the Police are called, the details relating to this must be carefully recorded.
9.4 In some instances it will be reasonable for the mobility of a young person to be restricted. For example, it may be reasonable to lock an outside door temporarily to restrict a child's mobility if she/he is likely to run out onto a busy road, or it is late at night and the child is unable to protect her/himself.  In some cases previous incidents indicate that the presence of others in a room with the child can inflame the situation.  In such cases it may be reasonable to temporarily leave the child alone to calm down, so long as the room remains unlocked, the room does not contain items that the child could use to cause harm to themselves, and a carer is able to observe the child at all times e.g. through a window.  It is probable that centres with soft play rooms are the only likely resource that will meet this criteria.
9.5 Great caution should be exercised in taking measures which may be seen as restricting the liberty of children.  Such actions should be restricted to circumstances where very urgent, immediate action is required, such as to prevent injury.  They should only be used rarely and only for very short periods of time.  They must always be fully recorded as to what was done and why.  The area is legally ambiguous and advice should, wherever possible, be sought from a senior officer before such techniques are employed.


10. Debriefing with the Child following an Incident   

10.1 Immediately following any incident the child will be supported with dialogue, consistent with their age and understanding. This may be with the carer(s) involved in the incident, or with another person designated by the child's social worker.  This must be constructive and designed to help the child understand the causes and consequences of their actions, and how to avoid similar situations arising in the future.  If a young person does not have speech, or has communication difficulties, all efforts must be made to use a communication specialist who is able to meaningfully consult with the child.
10.2 Immediately following any incident the child will be assessed for any signs of injury or psychological distress by such person as is designated by the manager on site, or the carer. To protect both the child and carer, it is imperative that a contemporaneous written record is made of this, which will form part of the full report of the incident.  A body chart must be completed to record injuries.  If they are of sufficient age and understanding, the permission of the child or young person must be sought before any assessment of injury is undertaken.  If a child or young person refuses to remove an item of clothing and a carer is concerned that there may be a hidden injury, they must seek immediate medical advice.  On no occasion will any assessment of injury by a carer involve invasive exploration.


11. Debriefing Staff/Carers Following an Incident

11.1 As soon as is practicable following any incident involving physical intervention, an appropriate supervisor will arrange a de-briefing session with the carer(s) involved.  This will provide valuable support to carer(s) who may be feeling vulnerable and/or shocked.  This may also need to include children and adults who witnessed the incident.
11.2 This practice will enable managers and supervisors to ascertain the carer(s) attitude towards physical interventions and the possibility that they may be becoming habituated to its use.  


12. Assessing Risk and Behaviour Management Plans

12.1 A child assessed to be at risk of needing physical intervention should be subject       for a BMP.  This will outline the strategies which will be used to defuse situations       and, where physical interventions may be necessary, the techniques carers will       normally aim to use.  It should also list any specific techniques which should not       normally be appropriate to use e.g. if a child has a physical disability.  This can       apply to any child in need including those looked after and those with a       disability.
12.2

A BMP is designed to help a child, not label her/him.  The child's social worker, or resource centre worker will discuss the need for a BMP with their team manager, and if they agree with the need for a BMP it will be drafted:

  • an incident
  • at a statutory review after if it is felt there is evidence of need following a risk assessment
  • at a placement agreement meeting if there is evidence of need
  • during an assessment if there is evidence of need
12.3 If there is disagreement as to the need for a BMP, or its contents, these will be resolved through the usual line management structure.  Both the Shared Care Panel and Placement Panel can be used for consultation purposes to assist in drafting BMP's.
12.2 Children who behave in ways which are considered dangerous, socially inappropriate or disruptive make special demands on carers and staff who care for them. They may pose a challenge to everyone involved in meeting their needs and helping them to make rewarding relationships. Whenever parents, carers, social workers, teachers or others indicate that a child may pose problems for those caring for them, or other children, there will be an assessment of the risk involved. The Risk Assessment  seeks to establish how and why the child uses the identified behaviour(s) and their effects, including a full description of those behaviours and any predictors such as the context in which they are likely to occur with times and triggers.
12.3 Where a significant risk is identified, the purpose of the Risk Assessment is twofold. Firstly, it enables arrangements to be put in place that remove or at least minimise the likelihood of any challenging behaviour arising, and secondly enables  arrangements to be agreed for minimising the likelihood of harm to anyone should the behaviour nevertheless occur. Taken together these arrangements form a BMP.
12.4 The field social worker allocated to the child shall be responsible for co-ordinating and communicating relevant information concerning the child to all parties. This shall include any behaviours which might pose problems for the carers and other health issues, and personal issues that may have bearing on a BMP, e.g. a history of sexual or physical abuse.  The social worker's assessment will indicate whether a Risk Assessment is needed in respect of the child's behaviour. Where it is needed, it will be co-ordinated by the social worker and any resulting BMP will be drawn up in collaboration with all those responsible for arranging and providing direct care.  Input from a Child Psychologist or Child Psychiatrist should be sought in appropriate cases.
12.5 There will be full consultation with parents, carers, social worker and as far as possible with the child themselves about the Risk Assessment and BMP. The BMP forms part of the child's Care Plan and is reviewed as part of any review of the Care Plan.  Changing patterns of behaviour over time may suggest a different approach may be more effective.  It must  also be  reviewed whenever there is an incident where physical intervention is used to avoid harm or there is a complaint by a child or another person about its operation.  The content of the plan and the role of all staff and carers in operating it must be drawn to their attention before or at the time of placement.
12.6 The BMP will record information and guidance to carers, how challenging behaviour might be avoided, who can be called-on before a situation escalates and who must be informed in the event of an incident occurring. The emphasis of the BMP will be on pro-active strategies of working with the child to avoid behaviour becoming unmanageable.
12.7 As part of the BMP there will be full consultation with the parents, carers, residential staff, social worker and where appropriate the child themselves, immediately following any incident where harm has occurred, or a physical intervention has been used to avoid it. This consultation will also include a review of the BMP.
12.8 In accordance with Bexley Council Violence and Harassment to Employees Policy, a full report of any incident of harm will be reported to the relevant Manager of Bexley Council and SPMS using the prescribed form  immediately following every incident.  It is important to record the incident in the workplace Accident & Incident Report Book .  Any written records must be made contemporaneously to ensure recollections are as fresh in people's minds as possible.
12.9 A full report of any incident using the prescribed form  will be reported immediately to the Team Manager having line management responsibility for the child's social worker.  It may be that foster carers will often be the only witness to an incident with a child in their care, it is therefore imperative that contemporaneous notes are made of the incident and that they contact their link worker, or the emergency duty team if out of hours, to report the incident at the earliest opportunity.  If there is evidence of an injury e.g. bruising, a body chart  should be used to record this and attached to the written report.
12.10 All incidents involving children with a disability will be monitored by the Shared Care Panel and those involving children without a disability will be monitored by the Placement Panel. A copy of the Incident Report will be forwarded by the Team Manager to the appropriate Panel Administrator for collation and review at Panel.
12.11

In accordance with Reg. 29 Schedule 5 of the Children's Homes Regulations, the Panel Administrator will also send a copy of the Incident Sheet to the Regulatory Authority  where applicable.

Ofsted is the Regulatory Authority:

Ofsted,
Bristol Office,
Freshfield House,
Redcliffe Way,
Bristol
BS1 6NL

TEL: 08456404040


13. Medical Advice

13.1 Some children may have medical conditions which could make them vulnerable to injury, or may have a history of self-harming or aggressive behaviour.  In such       cases medical advice should be sought about the forms of physical intervention       that can be used safely by the appropriate medical advisor and/or other health       professional (e.g. physiotherapist).
13.2 Equally, some carers may have medical conditions that could affect their ability to use some physical interventions safely.  In such cases the individual should be assessed by their doctor or Bexley Council's occupational health advisor.
13.3 Bexley Council's occupational health advisor should also be consulted if there is a need to assess any risk that may attach to using physical interventions with a particular young person e.g. by blood borne infections such as hepatitis B.


14. Holding Children

14.1 Children should not be held in the prone position (face down).  The risk of asphyxia is likely to be lowest when children are held in a seated position. If they are lying down, the risk of asphyxia will be least if they are lying on their side, and greatest when prone.  There is also an increased risk of facial injury in the prone position.
14.2 If it is known that children have been sexually, emotionally or physically abused, any physical interventions should be designed to ensure they do not have sexual connotations or remind the child of positions in which they were abused.


15. Review and Monitoring

This policy will be reviewed after 6 months of operation and then annually by the Head of Children's Commissioning and Quality Assurance in conjunction with representatives from SPMS, and children's services.


16. Complaints

16.1 If a child, a parent or a carer wishes to complain about any issues that relate to this policy, they should be advised to use the Bexley Council or SPMS Complaints Procedure.


17. In Conclusion

  1. Those working with children and young people need to be mindful of the following on an ongoing basis:
    • to work as a team wherever possible, whether in a work situation or as foster carers at home
    • be familiar with the individual care plan and Behaviour Management Plan (BMP) for each child
    • be sensitive to the child's needs and behaviours
    • notice changes and warning signs that may precede an incident
    • think ahead about how to react to situations
    • use strategies to prevent incidents whenever possible
    • use training opportunities and individual supervision to review practice and reflect upon incidents
  2. When faced with a potentially aggressive or violent situation, carers should:
    • deal with each child as an individual and follow the agreed BMP
    • keep calm
    • be aware of hazards and potential risks and try and make the environment safe
    • remember the safety of everyone present (including the carer)
    • put people before property (this may also include animals)
    • keep self and others at a safe distance if possible
    • look for a way out
    • use physical intervention as a last resort
    • use the minimal level of physical intervention required to bring a situation under control
    • call for help if this is required, but be aware that a "crowed" can inflame a situation
    • call the emergency services if this is the only safe option.
  3. When the incident is over and the child has calmed, carers should:
    • treat any accidental injury
    • reassure and calm those present
    • talk through the incident with those present/involved
    • reassure others and seek reassurance
    • write down an account of the incident using the prescribed form
    • inform a senior manager, other relevant professionals and the child's parent(s)
    • reflect upon the incident and learn from the experience
    • arrange to review the BMP
  4. When recording the incident it is essential to:
    • describe what happened
    • report who was present
    • describe who did what
    • confirm whether help was called (e.g. the Police) and how long it took for assistance to arrive
    • report any injuries sustained by anyone involved in the incident
    • list damage to property
    • evaluate the situation - why did it happen, how could it be prevented in the future
  5. When agreeing strategies to manage behaviour, BMP's should take into account the continuum of interventions available.
  6. Carers should always consider strategies to avert or deflect in the first instance, unless safety will be compromised e.g.:
    • allowing a child space
    • cajoling
    • talking
    • listening
    • reasoning
    • diversion
    • humouring
    • distraction
  7. If a physical intervention is required, in the context of the training given to them, carers may consider:
    • physically interposing between children
    • blocking a child's path
    • "holding" using prescribed methods
    • leading a child by the hand or arm
    • shepherding a child away by placing a hand in the centre of the child's back
  8. It is not reasonable force for carers to:
    • hold a child around the neck, or by the collar, or in any other way that might restrict the child's ability to breathe
    • slap, poke punch or kick a child
    • twist or force limbs against a joint
    • trip up a child
    • hold or pull a child by the hair or ear
    • hold a child face down on the ground
  9. See attached flowcharts for the process to use in undertaking a Risk Assessment, formulating a BMP, and its management and review.

Click here to view Bexley's After Incident Flowchart

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