Challenging Behaviour (CB) 2: Assessment

Functional Analysis As highlighted in the Introduction presentation, ‘challenging behaviour’ can be a very subjective issue. Therefore, we need to get very detailed, good quality, more scientific data to fully understand the behaviour. A ‘FUNCTIONAL ANALYSIS’ is an approach that helps us to UNDERSTAND WHY a CB is happening, by identifying what the behaviour is COMMUNICATING. This will then help us to develop the most effective, efficient and person-centred interventions by adapting aspects of the person’s environment, interactions or behaviours.

Functional Analysis The first place to start with an assessment is to summarise the person’s relevant history: Known medical/physical issues – e.g. type of stroke, diabetes, arthritis, visual problems, hearing difficulty, cardiac problems etc. Mental health – history of depression, anxiety, psychosis etc. Everyday functioning & current homelife – e.g. lives in 2 bedroom house with husband and pet dog, does all domestic chores & shopping independently, manages own finances, no known cognitive problems, some memory problems over past 2 years. Lifestyle & hobbies/interests – plays golf 2xweek, enjoys regular city breaks, enthusiastic gardener, regular gym user, goes out with friends for lunch every Saturday etc. Psychosocial (education, relationships, ‘personality’) – e.g. left school with 8 ‘O’ levels, large extended family with close relationship with cousin X, very outgoing and sociable and always willing to help anyone. Occupational history.

Functional Analysis - data If we consider the WHAT, WHEN, WHO & WHERE, we can start to work out the WHY – which will direct our interventions. This will usually involve collecting very detailed information about: WHAT the behaviour looks like (detailed description) WHEN is it happening: Date, time, duration WHO does it involve: Staff, patients, family, friends, cleaner etc. WHERE does it happen: Location – be specific e.g. corner in bathroom nearest the door; red chair in sitting room

Functional Analysis Sometimes we can quickly identify a pattern of behaviour, without having to start a detailed recording schedule. For example, ‘Jean’ may only exhibit CB (e.g. ‘agitation’, ‘shouting out’) when she wakes up in the early hours. It may quickly be established that she is disorientated when she wakes at this time, because she has known visual and cognitive problems and becomes frightened - wanting some reassurance or social contact to reduce anxiety. Or, ‘John’ may become noticeably quiet and not eat after family have visited, although he is interactive when the family are present. It may be that he feels very sad and lonely when family have left, particularly as his homelife is very family orientated and he spent a lot of his time since retiring looking after his grandchildren and arranging outings for his local Social Club- he may feel a greater sense of loss and isolation which may also be exacerbated if he is on a side ward, away from other people.

Functional Analysis - ABC Sometimes, we may not be able to work out what a person’s CB is communicating so easily - so we are not able to effectively respond to help them. Or, we may think that we have a good idea why a person is exhibiting CB, but our interventions don’t seem to help. We may then have to get much more detailed and objective information about the context in which the behaviour occurs.

Functional Analysis - ABC You will need to identify the CB in specific terms: E.g. ‘constantly pressing buzzer to ask for toilet’. Rather than just ‘Keeps wanting staff’. You will also want to consider how often you need to record the CB: If behaviours are constant or very frequent it may be better to record the information for a set time (e.g. in 10 or 20 minute episodes), several time throughout the day (or night). This will allow you to see if the behaviour is better or worse at particular times and this may also give an indication as to the WHY. If the behaviour is less frequent (e.g. 2 or 3 times a day), then it may be better to just record your information every time the behaviour occurs. When you have 5 or so recorded episodes or events, you can start to have a look at your data to look for patterns and identify the WHY? Also, make a mental note of when the behaviours DO NOT HAPPEN (e.g. when having visitors, after a good night’s sleep).

Functional Analysis - ABC We usually use ‘ABC’ charts (see examples in ‘Toolbox’) to document these details every time the ‘target’ CB occurs. This builds up the data over time, until we have enough information to start to identify specific patterns. From that, we have a better chance of identifying the FUNCTION (i.e. communication) of the behaviour.

Functional Analysis - ABC The ‘ABC’ stands for: Antecedent: What was happening just before the CB occurred? Again, thinking about the WHERE, WHO, WHEN Behaviour: Note observations, not generalisations! E.g. Punched x 2, spitting, shouting threats to kick, shouting for staff, throwing buzzer at staff, throwing buzzer on floor, sitting and refusing to??? etc. NOT just noting ‘aggressive’ or ‘unco-operative’ or ‘withdrawn’. Consequences e.g.: What happens following the behaviour? Does anything change as a consequence? How does the situation resolve?

ABC Chart Example – unusual pain complaints – ‘Anna’ DAY/DATE/ TIME ANTECEDENT What was happening immediately before the event – e.g. situation, people BEHAVIOUR Describe exactly how the behaviour started, what happened during and for how long CONSEQUENCES Describe exactly how the behaviour ended, who was there, what were people doing Monday 10/11/12 2:20pm Anna was sat in her chair by her bed watching TV. She was waiting for her daily physio session at 3pm. She had been interactive with staff and other patients and seemed settled, watching her TV. Anna pressing her buzzer (8 x in total) for staff and seemed agitated – complaining of pain in her R shoulder. Staff re-positioned her, but the behaviour continued and she was given pain relief. When the Physio came at 3:10pm to collect her, Anna was still complaining of pain in her shoulder and seemed quite agitated about this. The physio decided that the session should be cancelled and would try again tomorrow. Anna returned to watching her TV, sat in her chair. She asked for a drink and when this was brought to her at 3:20, her pain had settled and she had calmed. Tuesday 11/11/12 10:30am Anna was told by the physio (X) that she would collect her in 30 mins for her physio session, that had been rescheduled from the afternoon. Anna was sat in her chair, talking to the patient in the opposite bed. Anna pressed her buzzer and complained of pain in her R shoulder, she was repositioned, but continued to press buzzer (5 x) and said pain was worse each time. Pain relief given although Anna continued to call for staff and complain of pain. The physio returned at 11:10 and cancelled the session and requested that the Consultant was notified about the pain. Anna’s pain reduced by 11:20 and she was interacting with other patients and did not seem upset. Tuesday 11/11/12 10:30am Anna was in physio, with (Y) practicing sit to stand after a successful 10 mins of sitting exercises. She complained of pain in her R shoulder and became agitated and tearful and refused to continue with the exercises. The physio session was stopped and Anna returned to her bed with pain relief. Her pain settled after mins.

Summary of Presentations 1 & 2 Challenging behaviours are often communications about a person’s thoughts, feelings and experiences. Challenging behaviours may develop from a combination of a person’s medical condition, their environment, their psychological/emotional state, previous experiences and medication. Although they can seem to be random events, careful recording of the behaviours can often uncover WHAT the behaviour is trying to tell us. The final presentation in the Challenging Behaviour Module will focus upon interventions. Thank you for your interest.