Working with Challenging Behaviour in Neuro-Rehabilitation

Dealing with challenging behaviour is much the same in neuro-rehabilitation as it is in other care and therapeutic contexts. The following is the basis of a training workshop in progress aimed at increasing skills in dealing with challenging behaviour wihtin a neuro-rehab setting.

What do we mean by challenging behaviour?
Behaviours are actions that we can observe and record:
Hitting
Kicking
Biting
Spitting
Smearing
Self-harm
Swearing
Disinhibition
Sexualised actions
Verbal threats?
Stubborness?
Lack of insight?

Emerson’s definition
"culturally abnormal behaviour(s) of such intensity, frequency or duration that the physical safety of the person or others is placed in serious jeopardy, or behaviour which is likely to seriously limit or deny access to the use of ordinary community facilities"


How do we learn behaviours?
From reward (reinforcement)
Through association
From role modelling
From unique human ability of reflection on action/learning from mistakes?

How do we unlearn behaviours?
Through punishment?
Through negative reinforcement?
Through extinction?
Through rewarding alternative experiences

Why do challenging behaviours arise?
Behaviours or actions exist because they serve a function
Challenging behaviours are no different
Functions:
Get needs met
Communicate thoughts/feelings
Avoidance
Sensation

Maintaining and promoting rules & boundaries:
Don’t be afraid to say when CB is not appropriate- clearly describe to a client when behaviour unacceptable
Consistency is key
Maintaining equal/professional relationships
Promoting team approaches rather than split teams

Improved communication:
What is the behaviour trying to express?
Functional assessment/ABC analysis
Liaison with speech and language
Communication aids/development
Relationships

Proactive strategies and environmental changes:
Consistency is key: Follow nursing guidelines/plans
Observe and record what rewards apply to an individual
Assessment of Frequency-Intensity-Duration-Onset (FIDO)
Think about environment/places/people/promiximity etc
Make environment safe when addressing CB
Be aware of cognitive limitations when planning activities

Reactive strategies:
Consistency is key: following team nursing guidelines
Make sure people are safe
Firstly, state when behaviour is unacceptable
Secondly, guide toward alternative behaviours
Reward positive alternative behaviours
Team liaison
Try not to inadvertantly reinforce CB
Time out strategies only work if followed to the tee with no exceptions

Awareness of feelings/attributions:
Challenging behaviour can evoke strong feelings in us. Sometimes they create anger/sadness/guilt/dislike. Incidents can sometimes remind us of previous experiences, events or people.
The feelings are really important because:
They can influence how we respond and deal with the behaviour

Talking about CB to colleagues and learning from past events:
CB creates staff stress
Evidence says support/talking helps
Open culture of learning from mistakes
Psychology’s door is open if strong feelings arise

Responding to Challenging Behaviour Summary:
Maintaining and promoting rules & boundaries
Improved communication
Proactive strategies and environmental changes
Reactive strategies
Awareness of feelings/attributions
Talking about CB to colleagues and learning from past events