Challenging Behaviour 3: Interventions

Once we have developed a solid hypothesis (idea) about WHAT a person’s challenging behaviour is trying to tell us, we can start to think about implementing some appropriate interventions. Our interventions will also tell us whether our hypotheses are right or not. If our interventions are delivered correctly and the behaviour does not change, this would indicate that our hypotheses were not ‘on the ball’ enough – and we need to revise them! Interventions for challenging behaviour can be seen to fall into 2 main categories: Proactive strategies & Reactive strategies

Proactive Strategies Proactive strategies to prevent the development of challenging behaviours are preferable to reactive strategies as they minimise distress for the person and those around them (as the person does not have to engage in challenging behaviours in the first place). Some proactive strategies may only be able to be devised following functional analysis and may be very specific to a particular patient’s situation. However, we can implement general strategies that will help to lessen the chances of challenging behaviour developing for all patients.

Proactive Strategies Some proactive strategies are naturally implemented as part of good quality, person centred care – e.g.: Taking account of patient’s preferences & dislikes & giving choice when you can: E.g. used to getting up early/later, or going to bed earlier, shaving daily. Involving patients in their own goal planning. Good & regular communication about their rehab/care plan, interventions, discharge planning. Letting people know if there are changes to any aspects of their care or how long staff will be before they can attend to a request.

Proactive Strategies Some proactive strategies are naturally implemented as part of good quality, person centred care – e.g.: Regular interaction to see if the person is OK and just to maintain a degree of social contact. Recognising if any of their difficulties or disabilities are likely to impact upon their independent activities: E.g. do they have their correct glasses for reading/watching TV within reach, or the TV remote control, have their hearing aid in, things placed on their ‘good’ side for reaching, is the TV at an angle that they can see. Providing appropriate communication aids. Orientation aids in the patient’s bed area and on the Ward: E.g. clocks, date/day, Ward & Hospital name, relevant staff names (e.g. Consultant, named nurse), photos of staff on display.

Proactive Strategies Noticing any patterns when a patient becomes upset or agitated (e.g. too many visitors, just after visitors have left, mealtimes). Being aware of more general stressors and trying to reduce them e.g.: Pain, other illness such as colds, noisy or busy times, cognitive ‘overload’ such as giving too much information, communication problems.

Reactive Strategies – Positive reinforcement Even if we would like to REDUCE a patient’s challenging behaviour, it is better to achieve this by INCREASING more adaptive behaviours (which effectively respond to the behaviour’s communication), this make the challenging behaviour ‘redundant’! This approach is referred to as ‘Positive Programming’. This allows the patient to develop a more adaptive and independent range of behaviours. Positive Reinforcement involves giving some type of reward when a person exhibits a behaviour that is more adaptive. The reward has to be something that the patient finds pleasing. Positive Reinforcement INCREASES the likelihood that a behaviour will occur again. The best form of positive behavioural reinforcement is when we can help a patient develop an adaptive behaviour that is self-reinforcing (i.e. when performing the behaviour itself gives a desired reward).

Managing Anger, irritability and aggression Irritability can be cause by many things – such as boredom, low mood/anxiety, pain, noise, busy environments etc. and person-centred thinking can often help us to identify what may be triggering a patient’s irritability, so that we can help reduce their distress. However, it can also be a predisposing factor to a patient developing anger and aggression. Therefore, effectively managing a patient’s irritability can save a lot of difficulty later. Some ‘warning signs’ of irritability include restless of repetitive behaviour (e.g. Fidgeting or pacing, repetitive questioning/requests, obsessively looking for things). Use the skills that you are developing from this module to help you do this.

Managing Anger, irritability and aggression If you notice that a patient appears irritable or angry or is becoming aggressive, there are some simple things to remember to help diffuse the situation (or at least not make it worse). See the manual for more detailed information, but simple tips include: Be empathetic – try to understand why the patient may be feeling angry (even if we think they are being unreasonable). Ask what you could do to help. It’s easy to become agitated ourselves when people around us are being angry – try to keep calm and don’t be abrupt, dismissive or authoritarian. Give yourself time to deal with the situation – if you are worrying about the next 5 jobs you have to do & don’t have time to deal with the patient’s problems, you are likely to become irritable and angry yourself! Perhaps asks another staff member to cover your jobs for a minute until you deal with the situation.

Sexualised Challenging behaviour Some patient’s may display inappropriate (i.e. out of acceptable contexts) sexualised behaviour following stroke, due to their inability to inhibit their behaviour. These behaviours may be sexualised comments, making advances to others or self touching in public etc. These behaviours may happen because the patient is confused or they may not be able to inhibit their impulses or they may not see their behaviour as inappropriate because of their brain injury. Sometimes, what appears to be sexualised behaviour may be something completely different: Touching self because of genital discomfort of for general self- stimulation (i.e. as a consequence of boredom) or as a distraction from anxiety.

Sexualised Challenging behaviour We tend to feel a little uncomfortable or embarrassed when confronted with sexualised challenging behaviour and we may want to just ignore it or jump to rash conclusions – both approaches are likely to be ineffective and mean that we will not develop our skills in effectively managing this behaviour. Although it will probably be a little embarrassing at first, the behaviour should be discussed with the MDT, to get a more objective view of what the behaviour is and is not. You can then start to get an idea of what function the behaviour has – is it self- stimulation, does the patient have a UTI & is therefore trying to relieve genital discomfort, are they trying to tell you that they want to use the toilet etc? If a patient is making more purposeful physical attempts to inappropriately touch others (usually staff), then a simple strategy is to minimise stimuli that may trigger an unwanted sexualised behaviour (e.g. be aware of your own physical proximity to the patient and how you physically interact with them).

Lack of motivation Apathy or reduced motivation can have a significant impact upon a patient’s rehabilitation, although it is rarely to do with laziness. Often, it is either (or a combination of) mood disturbance, fear of failure or pain, cognitive problems, neurological apathy etc. Addressing the underlying components can really help and so any kind of therapy needs to start with a good rapport, person-centred goal attainment approach. Patients having rehabilitation following stroke can easily become deflated if their therapy starts to plateau or does not progress as quick as they would like or if they get secondary problems that hinder their progress or ‘put them back’ (e.g. Chest infections, UTI).

Lack of motivation It is important to try to ‘coach’ patients through these difficult times and you could try some of the ‘Motivational Interviewing’ strategies that can be found in the Manual and in other presentations. Try to keep patients goal focussed and emphasise what rehabilitation successes they have already made. A simple technique is to ask the person to compare where they are now, with where they were on the FIRST day of their stroke. Patients have a tendency to compare their current levels of functioning with those before their stroke – which is always going to be an unsatisfactory comparison. Getting them to compare where they are following some rehabilitation, with how they were when the stroke first happened will help them to view themselves as someone making progress, rather than someone who has lost a lot of what they had.

Medication It is not uncommon for medication to be used to help manage patient’s challenging behaviour when they are in hospital. However, we should always attempt to UNDERSTAND the behaviour, to help the person manage their behaviour more appropriately – rather than just trying to subdue the behaviour with medication. There are times when medication is appropriate, such as to treat a psychotic illness following stroke or severe confusion which leads to violence. Antipsychotic medication, anticonvulsants and benzodiazepines can carry quite significant side effects, which can interfere with a patients rehabilitation by impairing cognitive and physical functioning in a variety of ways. Medication alone should never be seen as long term solution to managing someone’s challenging behaviour – Functional Analysis and/or psychological interventions should always be undertaken. Antidepressant medications (such as SSRIs) can be helpful to treat underlying depression and anxiety (as well as hyper-emotionality), and there is some evidence to suggest that they can improve cognitive ability in the rehabilitation phase.

Summary & Conclusions Challenging Behaviours are important communications about a persons experience, thoughts, feelings and wishes. Fully understanding the communication is crucial to developing effective management strategies – Functional Analysis can help with this. Basic, good quality person-centred care and rehabilitation can also help prevent challenging behaviours from developing. A preferred method of behavioural management is to positively reinforce behaviours which make the challenging behaviour ‘redundant’. This helps the patient develop more adaptive behavioural ways of communicating and getting their needs met– ‘Positive Programming’. Please refer to your manuals for more detailed information.

Thank you for your interest!