Evidence Based Practice Symposium - McMaster University

used parents’ responses to their questionnaires to further refine
the questions – but the content came from clinicians. Focus on
problems – The CBCL and PSI-SF do not contain any
positive items and the number of positive items in the CPRS is
in the order of 5%. The QRS and SDQ contain 35% and 40%
positive items, respectively. Only the SSIS and the Vineland II
are weighted more heavily toward positive items. Impact on
parents - Child behaviour and the impact of the behaviour on
parents’ lives are inextricably linked, yet most measures do
not address the impact on parents. Four of the measures
(CBCL, SSIS, SDQ and Vineland II) do not contain any items
related to the parents’ emotions or experiences regarding their
child’s behaviour. Approximately 2% of the questions in the
CPRS pertain to the feelings of the parent; in contrast
approximately 50% of the PSI-SF and 63% of the QRS
address parents’ emotions and experiences. Variable content
- Several measures contained items that appeared to be related
to concepts other than child behaviour. The CBCL, CPRS and
SDQ each contain two items related to the way in which other
people perceive or treat the child. In addition, the CBCL
contains three items related to academic, speech or motor
problems and the QRS contains two items related to the
child’s excess of free time. The CPRS is noteworthy in that
approximately 8% of its items are related to the child’s
learning difficulties. Scaling - All of the measures use a
relatively narrow scale (3 to 5 points) to rate the frequency of
each behaviour. The SSIS is significant in that it rates the
importance of items in addition to their frequency; however, it
does so for the positive items only. Negative items in the SSIS
are rated only with respect to their frequency.
Discussion
The results from our analysis indicate that common
behaviour measures contain items developed primarily from
the clinician’s perspective; emphasize the frequency of
negative behaviours; and generally do not address the impact
of the behaviour on the parents. Given these findings, we
suggest that there are several other important factors to
consider when assessing challenging behaviour and evaluating
the outcome of a behavioural intervention:
• Each child with challenging behaviour and their family is
unique – what is distressing and causes dysfunction for one
family may not be a problem for another family. Thus it is
important to try to acquire an individualized sense of this
child’s behaviour in this family.
• It is not merely the frequency of occurrence that
characterizes a challenging behaviour. Intensity (ranging from
minor to extreme manifestation of the behaviour), safety (i.e.
dangerous versus difficult), duration and social isolation are
also features of the behaviour.
• Eliminating the behaviour entirely may take a very long time
or may not be achievable. Perhaps it is possible to change
some aspects of the behaviour that are most distressing to
parents, and thereby reduce its impact.
• Rather than scoring a large number of behaviours on only
one parameter (i.e. frequency of the behaviour), it may be
more insightful to score a few behaviours in greater detail (i.e.
on several parameters). Each parameter could be scored with
respect to the degree of problem it poses for the parent, i.e. on
a scale of 1 to 10 where 1 represents a slightly problematic
issue and 10 represents an extremely problematic challenge.
This method is similar to that used in the Canadian
Occupational Performance Measure (Law et al., 2005).
The parameters of a particular behaviour might be
defined in the following manner: frequency (how often the
behaviour occurs), amplitude (the intensity with which the
behaviour is manifested), duration (how long a particular
occurrence of the behaviour lasts), location (where the
behaviour occurs), and time of day the behaviour occurs.
There are several advantages to this method of
looking at a child’s problem behaviour. First, parents are able
to focus on a few behaviours of greatest concern to them
rather than a large number of pre-selected behaviours
addressed in the items of standard measures, many of which
may not be relevant to their family at that point in time.
Second, since parents identify the problem behaviours
themselves, the measure is always culturally relevant, never
out-of-date and tailored to the unique situation of each family.
Thus it embodies family-centred practice and the concept that
parents are the experts on their children and the best reporters
of the behaviours and their impact. Third, analysis of various
parameters of the behaviour enhances understanding of the
behaviour and identifies specific aspects of the behaviour to
target for intervention. Finally, use of a 10-point interval scale
rather than scales such as “never/sometimes/often” should
improve the ability of the instrument to measure change.
Conclusion
Popular child behaviour measures tend to measure
the relative frequency with which a large number of possible
behaviours occur. When designing interventions for children
who exhibit challenging behaviours, it may more insightful to
have parents identify a few behaviours of primary concern and
analyze these in greater detail. Given the length of time it
takes to change most challenging behaviours, it may be
possible to improve the situation by addressing the most
problematic features of the behaviour and thereby shape the
behaviour to a more acceptable manifestation. The key
principle described in this paper is to rate each parameter
(frequency, amplitude, duration, location, time of day) with
respect to the degree to which it poses a problem for the
parents.
Key References
Emerson, E. (2001). Challenging behaviour: analysis and
intervention in people with severe intellectual
disabilities (2 nd ed.). Cambridge, UK: Cambridge
University Press.
Fox, V., Vaughn, B.J., Wyatte, M.L., & Dunlap, G. (2002).
We can’t expect other people to understand: Family
perspectives on problem behaviour. Exceptional
Children, 68, 437-450.
Keen, D., & Knox, M. (2004). Approach to challenging
behaviour: A family affair. Journal of Intellectual &
Developmental Disability, 29, 52-64.
Turnbull, A.P., &Ruef, M. (1996). Family perspectives on
problem behavior. Mental Retardation, 34, 280-293.
Werner DeGrace, B. (2004). The everyday occupation of
families with children with autism. American Journal
of Occupational Therapy, 58, 543-550.
Acknowledgements
The authors wish to thank Dr. Lucyna Lach for
providing the database, Dr. Nora Fayed for her advice
regarding analysis of measures and N. Nemeth whose
observations and insights served as the catalyst for this project.