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A Review of an Approach and Methods of Assessing Risk Arising from Behaviour that Challenges. Rai Turton [email protected] Behaviour that challenges (BtC): Causes harm or presents risk of harm. A challenge to services:

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A Review of an Approach and Methods of Assessing Risk Arising from Behaviour that Challenges

Rai Turton

[email protected]

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 harmA simple example (uncontextualised)
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


  • 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


  • 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

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.


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)