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Challenging Behaviours - Fact Sheet
 Challenging behaviours are those behaviours that threaten the safety of the self or others, or limit access to the community.
Individuals and communities have a tendency to judge people by their behaviour and anyone who acts outside the acceptable boundaries is in danger of being excluded. People with an acquired brain injury may ‘break the rules’ associated with:
- How close to stand to other people
- When it is appropriate to interrupt another person who is speaking
- When and how to show emotions
- How to interpret and respond to nonverbal communication
- What parts of a person’s body may be seen naked or touched
- When to speak and how to get a point across.
In the early stages of recovery these problems may not be obvious. However long-term irreversible brain damage sometimes occurs resulting in specific problem behaviours.
Types of Challenging Behaviours
Impaired social behaviour is often evidenced by childlike behaviour, self-centredness, tactlessness, reduced emotional sensitivity and lack of gratitude. Individuals may show marked changes in their social skills and self-care. Impaired control may be displayed in a number of ways including  Impulsivity (acting first & thinking later), verbal and physical aggression, increased/decreased libido, financial irresponsibility, alcohol and drug abuse, poor frustration and stress tolerance, impatience, restlessness, and a lack of mental flexibility with the need for a highly structured and routine environment. Common emotional difficulties, such as depression and anxiety may lead to challenging behaviours such as withdrawal and avoidance. Increased dependency, which may be related to emotional problems, may also lead to increasing demands for attention from caregivers.
It is not uncommon for people with brain injury to experience a lack of insight into the nature and effects of their injury, which may lead to feelings of frustration; particularly if they are forced to rely on others to do things they might normally do for themselves. As individuals gradually develop higher levels of self-awareness into the impact of their post-injury changes, the most common reactions include depression and anxiety. Some individuals can experience a catastrophic reaction to their losses such as anger, fear, helplessness, suspiciousness and paranoia. Some people with acquired brain injury may lack trust in other people and become suspicious about their actions and ideas. In some cases, this leads to the development of paranoid tendencies in which the person has fixed beliefs and acts in a guarded and secretive manner.
How others respond to these behaviours will be an important factor in the successful rehabilitation of the individual, as well as influencing the quality of life of family and friends. It is important when challenged by a person whose behaviour has changed as a result of an acquired brain injury, to keep the emphasis on behaviour rather than personality. This helps to:
- Maintain a greater sense that change is possible
- Specify what is happening in clear and concrete terms
- Direct any disapproval away from the individual and onto the behaviour.
While the exact causes of challenging behaviour are not well understood, the two main causes of behavioural changes that follow an acquired brain injury stem from:
- A learned response reinforced for the individual in their environment
- The inability of many to control their behaviour due to the direct effects of their injury.
Responding to Challenging Behaviour
Effective responses to challenging behaviour rarely happen by chance. A successful strategy will require a disciplined approach that coordinates and implements a number of steps. The steps for responding to challenging behaviour include:
- Observing and measuring the behaviour
- Identifying what causes or contributes to the behaviour
- Developing realistic expectations about change and how to measure the results
- Identifying and evaluating the possible approaches and strategies for change
- Developing a behaviour management programme
- Implementing the programme
- Monitoring progress and reviewing the programme
- Maintaining gains and making further progress.
Observing and measuring the behaviour
During this initial assessment stage the main aim is to get a clear understanding of the specific behaviours that cause concern. Each challenging behaviour requires a different strategy. It is important to prioritise which category of behaviours will be addressed first. Measuring the behaviour involves questions such as how often and where does it occur, how long does it last and how do people react to it?
Identifying causes and influences of challenging behaviour
The causes or influences of challenging behaviour may be divided into: individual factors, environmental factors and factors related to people. Severe behavioural difficulties may require assessments conducted by professionals. These assessments will help provide insight into the person’s level of Cognitive and psychosocial functioning, the effects of the brain injury, the impact of the environment and the influence that mental illness may have upon the behaviour. To make sense of what causes or influences the behaviour, the antecedent, behaviour, and consequence (ABC) model can be used:
- Antecedent - examines what usually happens before the behaviour, and particular triggers or events that may set off the behaviour
- Behaviour - an analysis of the ‘behaviour’ part of the model examines what happens
- Consequence - analysis involves identifying immediate and delayed reactions following the behaviour from the individual, other people and the environment.
Developing realistic expectations and measuring results
Setting realistic goals for change involves:
- The degree to which the behaviours may be eliminated, reduced, increased or influenced
- How long the behaviour has been present (before and after the injury)
- The individual’s capacity to control the behaviour
- The individual’s level of insight and reasoning skills
- The individual’s level of motivation
- The environment (structure and consistency)
- The ability and willingness of people around the person to assist with strategies
- The ability and willingness of the person to cooperate with other people.
Behaviour should be measured prior to the intervention to provide a ‘baseline’ against which progress can be compared. The period of time spent measuring the behaviour needs to be long enough to provide a representative view.
Identifying and evaluating possible approaches and strategies for change
There are many different approaches and strategies to encourage individuals to change their behaviour. The suitability and effectiveness of each option will vary according to the individuals with a brain injury, the people around them and the environment. Some of the most commonly used and successful approaches are outlined as follows:
- Modifying the environment or routine
- Giving the person feedback about the behaviour
- Motivating the person to change
- Changing expectations and demands placed upon the person
- Teaching the person new skills and behaviours
- Changing how people around the person react
- Psychological support
- Medication.
Developing a behaviour management programme
The key questions in developing a behaviour management programme include:
- What are the specific behaviours to address?
- What is the current pattern of behaviour?
- What is the goal for change?
- What are the steps towards achieving the goal?
- How will change be recognised and monitored?
- What approach or combination of approaches is most likely to be effective?
- How can the person with the acquired brain injury have as much control, responsibility and participation in decision-making, as their capabilities will allow?
For all carers and family members involved in the programme, a consistent approach is often the most significant factor influencing success. The expectations of behavioural change also need to be clearly defined and realistic. It may not be possible to change all behaviours at once, or in all situations.
A Summary Checklist for Responding to Challenging Behaviour
- What are the different challenging behaviours displayed by the person?
- Which category of challenging behaviour will be focused upon initially?
- Why is the behaviour a problem?
- What pattern has been observed for each target behaviour?
- What are the specific target behaviours within this category?
- What seems to cause or contribute to the behaviour?
- What are the expectations of change (individuals versus family member or carer)?
- How will change be measured?
- What are the possible approaches and strategies for change?
- Which approaches and strategies are most likely to be effective?
- What level of control and participation can the person with a brain injury have?
- What are some potential problems in the programme and how will these be overcome?
- What is the time frame for the programme?
- How will progress be measured and what outcome measures may be used?
- When will the programme be reviewed with any necessary modifications?
- How will gains be maintained and generalised over time?
- Can further progress be made by extending the programme to different behaviours?
- Have the rights of the individual been fully protected within the programme?
The Right to Stay the Same
It is important not to lose sight of the person’s rights. In spite of all the best intentions, the person concerned may not want to alter their behaviour. If this is the case, then they have the right to behave in a way that challenges the norms of the community. People cannot be punished for their behaviour unless it is by the law. Neither can they be restrained against their will or forced to conform to another person’s rules without consent. The excuse ‘It is for their own good’ is not sufficient reason to deprive another citizen of their rights under the law.
The long-term effects of a brain injury may not be evident for some time. At best, those with a mild brain injury may be able to return to work but will spend the rest of their lives battling a range of cognitive problems. Others will find themselves dependent on others for the rest of their lives, while the most unfortunate may never emerge from a state of Coma.
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Challenging behaviours 
