Assessment and management of challenging behaviour

1. Assesment and Manganement of
Challenging Behaviour
Dwi Kartika Rukmi
kartikarukmi@ymail.com

2. INTRODUCTION
 Brain injury, traumatic (TBI) or acquired (ABI), can
result in a constellation of cognitive deficits, mood
disturbances, personality changes and behavioural
problems.
 These may either be temporary or permanent and
may result in partial or total disability.
 Challenging behaviour can describe as ‘... having lost
control over everything. They are physically,
emotionally and cognitively dislocated.’

3. Pathophysiology
Type of injury
• the nature,
• location and severity of
the injury,
• diffuse effects,
• secondary mechanisms
of injury,
• the presence of
seizures
Demographic factor:
• Age,
• medical health,
• history of previous
brain injury,
• pre-morbid level of
function,
• history of any
substance abuse
(drugs/alcohol),
• psychiatric history and
• psychosocial factors
Personality
characteristic
Brain injury in
frontal or
temporal lobe,
disruption of
limbic system
Behavioral
challenging
Specific
behavioral
challenging
Frontal lobe
syndrome or
executive
dysfunction
syndrome

5. Frontal Lobe Syndrome
 Neurological and/or
psychiatric symptoms might be detected
due to damage of frontal lobes as
detected in damages of many brain
regions.
 These often interact causing frustration,
intolerance and reduced capacity to
control mood, giving rise

7. Executive Dysfunction Syndrome
 Executive functions represent a constellation of
cognitive abilities that drive goal-oriented behaviour
and are critical to the ability to adapt to an ever-
changing world.
 Executive functions can be split into four distinct
components: working memory, inhibition, set shifting,
and fluency.
 Executive dysfunction encompasses a wide range of
deficits: problem solving, poor organising and
planning skills, perseveration, and inability to inhibit
action

8. Epidemiology
 Specific problems of cognition and mood were
consistently reported in all survivors of mild,
moderate and severe TBI (47%, 48% and 76%
respectively).
 Behavioural problems were identified in about 30% of
severely brain injured patients while they were in
hospital, but that this figure increased to
approximately 80% once these patients had returned
home to their families

9. ASSESSMENT

10. ABC CHART
 The ABC chart: The tool analyses the behaviour of
the patient according to possible triggers
(Antecedents) of the Behaviour, and possible
maintainers (Consequences) of the behaviour.

11. Agitated Behavioural Scale (ABS)

12. Agitated Behavioural Scale
(ABS)
 It takes within 10 minutes
 Nurses can assign a number ranging
from 1 (absent) to 4 (present to an
extreme degree) for each item
 Total scores range from 14 (no
agitation) to 56 (extremely severe
agitation).

13. Overt Aggression Scale (OAS)
 A 16-point scale designed for rating
aggressive behaviour, which originated
in the psychiatric setting
 The OAS measures global aggression
as well as four subscales: verbal,
physical towards objects, physical
towards self and physical towards
others.

15. Assessing Emotional Disturbance
 Katz Adjustment Scale (KAS)
 Katz and Lyerly in 1963)
 Designed for the non-professional, it is
a short and relatively easy scale to use,
covering a wide range of emotional
behaviours observed in the TBI
population.

16. Assessment of post-traumatic
amnesia (PTA)
 It is a valid measure for predicting outcome after TBI
but also provides guidance for commencing further
functional assessment and active therapy
 There are a number of prospective measurement
scales available:
1. The Westmead PTA Scale (Shores et al., 1986)
2. The Oxford PTA Scale (Artiola et al., 1980)
3. The Galveston Orientation and Amnesia Test
(GOAT) Levin et al., 1979)
4. The Julia Farr Centre PTA Scale (Geffen et al.,
1991).

17. MANAGEMENT

18. General Principles

19. Over-stimulation and under-
stimulation
 Busy ward  excessive sensory
stimulation and loud noises.
 Over stimulation: Place patient in quitter
area, Schedule rest period, Tasks
should be presented one at a time so as
to prevent overload of information.
 Under stimulation: balance the need for
a safe environment with activities

20. Wandering

21. Sleep-wake disturbances
 Mild insomnia or daytime sleepiness to a complete
reversal of their sleep-wake cycle
 TBI resulting in sleep disturbances post injury role
of the hypothalamus in the sleep-wake cycle
disturbance
 Turning lights off and on at appropriate times,
opening and closing curtains, keeping wall clocks
accurate and repeated reorientation by staff and
carers in a non-confrontational manner.
 Pharmacological interventions, such as the
administration of night sedation, to reverse the sleep-
wake cycle may also be helpful.

22. STAFF INTERACTIONS AND
BEHAVIOURS
 Patients often experience difficulties in
perceiving and processing information
accurately  misinterpret  irritability/hostile
 To help with reorientation, incorrect
information should be corrected
 Distraction techniques may also be used to
prevent challenging behaviour from
escalating.
 Use alternative interaction (see the box)

23. Alternative interactions

24. PHARMACOLOGICAL
MANAGEMENT

25. PHYSICAL RESTRAINT
 In cases where there is no obvious antecedent to the
behaviour and all other methods to control and
manage the behaviour(s) have failed, then physical
restraint may be required as a last resort to protect
the patient and others
 ‘... any device, material or equipment attached to or
near a person’s body and which cannot be controlled
or easily removed by the person and which
deliberately prevents or is deliberately intended to
prevent a person’s free body movement to a position
of choice and/or a person’s normal access to their
body.’

26. General Principles of Restraint

27. Consideration of restraint

28. Methods of restraint

30. Outcome of restraint

31. REFERENCES
 Woodward, S.W., Mestecky,A.M.2011. Neuroscience Nursing Evidence Based
Practice. United Kingdom: Wiley-Blackwell
 Fleminger S, Greenwood RJ, Oliver DL. (2006) Pharmacological management
for agitation and aggression in people with acquired brain injury. Cochrane
Database of Systematic Reviews (4) CD003299. DOI: 10.1002/14651858.pub2.