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According to Ruby’s case notes she has a limited vocabulary but can make her needs known; she can speak English and a language of her native country. A speech and language report noted that Ruby has comparatively superior expressive language skills but her verbal comprehension is inconsistent and unreliable.

Further information was obtained from informal conversations with the referrer, the manger of Ruby’s residential home and her previous care manager.

Ruby was born overseas and has a younger brother. The family lived abroad until the 1980s when Ruby, her mother and brother moved to England because there were no suitable schools for Ruby in their original country. Ruby attended a community special school for children with severe learning difficulties until she was 19. She moved into the residential home for younger adults with severe learning disabilities sixteen years ago. Ruby’s mother, father and brother all currently live overseas.

Ruby attends a day centre for people with learning disabilities.

Functional Assessment Interviews (FAI, O’Neill et al., 1997) were conducted with the manager of Ruby’s home and her day centre link worker to obtain a description of Ruby’s ‘challenging’ behaviour. At home Ruby lines up items including the television and food jars to the edge of shelves and tables and shuts doors. She also eats food, often peanut butter or mayonnaise, when alone; amounts range from one teaspoonful to half a jar. At the day centre she moves items and has ‘tantrums’. I had difficulty understanding why some of these behaviours were regarded as ‘challenging’, although some do pose a potential risk to Ruby and others.

The initial assessment indicated attention from staff may be a maintaining consequence of the behaviours, which may be perceived by Ruby as rewarding. Lack of information made a comprehensive formulation impossible. An extended assessment was therefore necessary to test my initial hypotheses and structure an intervention.

EXTENDED ASSESSMENT

The extended assessment focused solely on Ruby’s behaviour at home as no further incidents were reported at the day centre.

I compiled a history of Ruby’s ‘challenging’ behaviours using information obtained from her case notes and conversations with her care manager and home manager, to clarify how long they have been a concern and whether they have altered, and to identify any historical events that might have contributed to them.

ABC recording charts were completed by staff at Ruby’s home to obtain a baseline measure of her behaviours and provide further information. Analysis of these charts revealed that almost every consequence results in Ruby receiving the direct attention of staff members, indicating this attention may reinforce her behaviour. Ruby’s behaviours decreased upon her return from a holiday with her family.

I conducted an ecological analysis which considered Ruby’s physical, interpersonal and programmatic environments, to identify how well her environment meets her needs and help me understand what environmental changes may be required to provide the necessary support for her.

FORMULATION

My initial hypothesis was supported, and the information I obtained subsequently to the pre-assessment enhanced my understanding of Ruby’s behaviour by highlighting a lack of opportunities for social interactions when at home, which might lead to her becoming bored. Ruby’s behaviours may be maintained by the attention she receives from staff, providing interaction and stimulation. Ruby’s behaviours may also result in some staff becoming irritated with her, therefore more likely to spend time in the office rather than interacting with her.

The possible impact on Ruby’s vulnerability of her family living overseas and her lack of opportunity to interact with others of a similar cultural background to her also emerged as themes. Apparently Ruby’s ‘challenging’ behaviours began within a year of her parents moving overseas, and appear to have ceased at the day centre following her most recent visit to her family. Having been brought up in an Asian family until she was 19, Ruby now has no opportunity to access her native culture apart from talking to her mother on the telephone or extended visits to her family.

Although Ruby eats regularly during the day it is possible she takes food because she is hungry; this behaviour being maintained by the subsequent reduction in her hunger after eating.

RECOMMENDATIONS

The recommended support plan suggested various interventions to reduce Ruby’s ‘challenging’ behaviour, improve her long term quality of life and enable her carers to better understand her needs.

Ecological manipulations were recommended to make Ruby’s environment more compatible with her needs. To improve Ruby’s quality of life she should be given regular opportunities to talk about her family with staff made familiar with her background, found a culturally suitable befriender to enable her to talk about aspects of her cultural background, and given the opportunity to participate in active support, enabling her to become more engaged in the domestic aspect of living at the home. To reduce the frequency of Ruby eating food inappropriately she should be provided with a snack to eat at night. Positive programming should develop Ruby's functional skills and contribute to reducing the occurrence of her challenging behaviour by giving her the opportunity to participate in active support and develop new domestic skills. The frequency of Ruby’s challenging behaviour may reduce if she is supported to develop strategies to initiate more casual communication with staff members rather than simply to make specific requests. An improvement in Ruby’s quality of life might be achieved if she is referred for counselling to explore and express her emotions, in particular missing her family.

I suggested a staff meeting be called to share the formulation of Ruby’s difficulties and enhance staff confidence in implementing the support plan.