A Review of an Approach and
Methods of Assessing Risk
Arising from Behaviour that
Challenges
Rai Turton
rai.turton@gmail.com
Behaviour that challenges (BtC):
Causes harm or presents risk of harm
A challenge to services:
To support safely in least-restrictive
environments with maximal social inclusion
Risk assessment:
Estimating the probability and severity of future
harm
A simple example (uncontextualised)
High
Probability
Medium
Probability
Low
Probability
Minor
Harm
Moderate
Harm
Severe
Harm
The need for accurate and
contextualised risk assessment
●
●
●
Under-estimation of risk → harm occurs →
increased restriction
Over-estimation of risk → unnecessary
restriction
Lack of contextualisation → defensive support
→ unnecessary restriction
Focus of this presentation
This presentation focuses on approaches to
risk rating.
Contextualisation is mentioned when
appropriate but not properly addressed
because it is too large a topic.
Two risk-rating methods developed
for people who have LD
The BILD method (Powell, 2005)
Included harm: physical injury/illness, criminal
offending and property damage
The Mersey Care method (Greenhill et al., 2008)
Includes the same harm and also emotional harm,
restriction and social exclusion
Both methods actuarial, risk rating based on severity
and frequency of previous harm
Both assign numerical value to severity of harm and
modify ratings according to previous frequency
Both embed risk assessment in support and risk
management planning
Example: Rating risks using the
BILD method (non-contextualised)
A person who caused small abrasions four times in
the past month
●
Injury weight = 3
●
Frequency weight (4-12 per month) = 9
●
Risk score = 12, risk rating = high
A person who caused a broken leg in the past month
●
Injury weight = 4
●
Frequency weight (< 4 per month) = 8
●
Risk score = 12, risk rating = high
Sources of information
●
Carers' records, e.g. care notes, daily diaries
●
Incident reports
●
●
Formalised records of aggression, e.g. Overt
Aggression Scale
Structured and unstructured observations
“A-B-C” analyses of records will support
contextualisation.
In simplified form:
In situation X, the risk of (harm) is (rating);
In situation Y, the risk of (harm) is (rating).
Strengths and weaknesses of the BILD
and Mersey Care methods of risk rating
Strengths:
●
●
●
Objectivity: Focus on previous events and use set
methods to assign values and rate risk
Congruent with harm-based definition of behaviour that
challenges
Can use a range of information-collecting methods
Weaknesses:
●
Use arbitrary weights
●
No clear method of contextualising risk
Alternative methods
Forensic risk assessment:
●
Some scales adapted for people who have LD
●
Predict a limited range of outcomes
●
Risk factors not well matched to those found for
BtC per se
Challenging behaviour scales:
●
●
Limited capture of harm
No established method of deriving risk ratings or
contextualising risk
Suggestions
Use adapted forensic instruments for those cases in
which the predicted outcomes and the risk factors
are appropriate.
Use the BILD or Mersey Care procedures but be
aware of the hazards of their weighting systems.
Identify situational factors that modify risk and qualify
risk predictions accordingly.
Contribute to the development of better methods.
References
Greenhill, B., Whitehead, R., Grannell, M. et al.
(2008) Human Rights Joint Risk Assessment and
Management Plan (HR-JRAMP), Mersey Care NHS
Trust.
Powell, S. (2005) Risk in Challenging Behaviour: A
good practice guide for professionals. BILD
Publications, Kidderminster.
(Turton, R.W. (2014) Assessing risks arising from
challenging behaviours: A model and a brief review
of existing resources. Advances in Mental Health
and Intellectual Disabilities, 8, 32-42)