Handling Behavioural Problems

Russell Sheldrick, Consultant Clinical Neuropsychologist

Some background terminology

Emerson, a psychologist working with children with learning disabilities, defined challenging behaviour as behaviour that:

  • jeopardises the physical safety of the person and others.
  • limits the ability to use ordinary community facilities

This implies that challenging behaviours do not simply entail behaviours that are physically harmful but also behaviours that make normal daily activities (e.g. a trip to the supermarket or to the day centre) for the person and their carer difficult.

Rules of Human Behaviour

All behaviour is shaped by basic principles, which if understood, can help to understand why challenging behaviours occur. These behavioural rules were first discovered by psychologists in the 20th century. 

Classical Conditioning – what comes before the behaviour
Pavlov (1849-1946) is famous for his experiments on classical conditioning in dogs. Based on his observation that dogs salivate more when they are presented with food, he trained dogs to associate food with the sound of a bell by ringing a bell before each meal. Very soon, he found that dogs started to salivate every time they heard the bell, even if no food was presented. In this classic experiment, Pavlov uncovered one of the most important rules of animal and human behaviour: that behaviour is governed by association. The dogs learnt to associate the arrival of food with events that happened immediately beforeit, i.e. the ringing of the bell.

Similar examples can be observed in human behaviour. For example, staff on a hospital ward noticed that a patient was always aggressive to one of the nurses. When they started examining his behaviour, they realised that this nurse was responsible for administering the patient’s daily injections. The patient had associated the pain of the injection with what happened immediately before it, i.e. the arrival of the nurse, and so was aggressive to her every time he saw her, even if she wasn’t about to administer the injection. These examples show that, in order to better understand behaviour, it is important to identify its triggers, by looking at what happened immediately before the behaviour.

Operant Conditioning - what comes after
Skinner (1904-1990) is famous for uncovering another important principle of behaviour: behaviour is reinforced by its consequences, or what happens immediately after it. If the consequences of a particular behaviour are pleasant, then this behaviour will increase; if they are unpleasant, then the behaviour will decrease. For example, in the case of the nurse, the fact that she left the room rather than continue to administer the injection meant that the patient’s aggressive behaviour was positively reinforced and that he would be more likely to do it again to avoid another injection.

In order to understand specific behaviours, we need to understand what their function is by identifying the triggers and consequences that sustain them. 

Assessment of Behaviour

When confronted with a challenging behaviour, it is important to think what function the behaviour plays for the person. Based on our understanding of how triggers and consequences affect behaviour, we can perform a detailed assessment of the behaviour by asking the following questions:

  • WHAT is the behaviour?
  • What happened IMMEDIATELY before?
  • WHERE did it happen?
  • WHO with?
  • HOW often?
  • WHEN?
  • What happened IMMEDIATELY AFTER?

For example, take the following incident:

A physiotherapist visited Mr X in hospital to help him with some physical exercises. She approached his bed from the left side and took his hand. Mr X retaliated by swearing at her and hitting out. The physiotherapist attempted to calm him but then left without carrying out the treatment.

Assessment of the behaviour involved keeping a record of other instances when Mr X had struck out at staff and trying to answer the questions listed above. The results showed that Mr X always struck out when he was approached from the left side and that he tended to be more aggressive with female members of staff. Incidents were also more likely to happen in the morning, as Mr X was waking up and still feeling a little disoriented. It turned out that Mr X had a visual impairment on the left side so could not see members of staff approaching on that side. His behaviour could be understood in terms of a defensive reaction to being startled, which was exacerbated by feeling groggy and disoriented in the morning. It was decided that all treatment should be administered in the afternoon, preferably by a male member of staff. All staff were asked to approach Mr X on his right side (where he could see them) and talk to him so that he was not startled. Following these interventions, Mr X’s behaviour improved and there were less incidents of aggressive behaviour.

Interventions

Once the specific behaviour has been assessed, one needs to think carefully about how to intervene. Interventions should always be based on a thorough assessment of the challenging behaviour. Interventions which prevent the behaviour from happening in the first place are always preferred. It is important to think what can be changed in the person’s environment as well as their interaction with others in order to reduce the likelihood of challenging behaviours.

Step 1: Changing Triggers

a. Changing the environment
The first thing to think about is whether there is anything we can change in the person’s social and physical environment. Different people have different needs for stimulation in the environment.

Some people get overloaded and may need less stimulation in terms of:

  • noise
  • lighting
  • number of people
  • sudden approaches

For example, busy places like supermarkets may cause people to feel over stimulated.

Challenging behaviours can also occur because people are under stimulated and are in need of:

  • regular activities
  • social interaction

Sometimes, getting the right balance can be a bit of juggling act as some people may be apathetic if understimulated but easily get agitated if they are stimulated. Some people have very rigid routines and may become agitated if their routines are interfered with. This is not necessarily a sign that they are bored or understimulated. Rather, it may be their way of achieving a sense of security and meaning in their life, and gaining some control over their situation. If the routines are disruptive to other people, it may be an idea to gradually change the content of the routine so that they become more meaningful and are helpful to others (e.g. helping with domestic chores as part of routine). 

b. Changing our communication
Aside from the immediate environment, it is important to think about how our communication can affect the person’s behaviour. Confronting someone about their behaviour can often lead to rows, which lead to yet more challenging behaviour. One way to avoid this is to ‘choose your battles’ and only focus on those situations that are causing the most trouble. For example, Mrs Y is developing a weight problem because she has started eating a lot of sweet foods and doesn’t do much exercise. Mr Y has tried confronting his wife about her eating habits and even withdrawing sweet foods altogether, but this only leads to more irritability and agitation on her part. As an alternative, he decides to avoid confrontation and give her low-fat biscuits instead, thus helping to keep her weight down. 

Another alternative is called the ‘de-escalation technique’, which can be used to avoid arguments when people are agitated or aggressive, as in the following example:

Mr Z has gone into respite care for the first time. He is very agitated and keeps shouting at the staff to let him go home. The staff want to give him a chance to settle down and try to avoid entering into a confrontation. According to the de-escalation technique, the first thing to do is to acknowledge the person’s emotion, and tell them you want to understand why they are angry, possibly drawing them away from the immediate situation (e.g. away from other people, into a quiet room). It is then important to try and engage the person’s attention by initially agreeing with certain elements of their concern (e.g. that they feel trapped or don’t know anyone) and siding with them. Once the person is engaged and talking, it is easier to shift the topic of conversation gradually away from their problem onto other things. Adopting a calm behaviour encourages the other person to mimic your body language and also remain calm.

Step 2: Changing the consequences

Changing the consequences of a particular behaviour may help a person understand what is socially acceptable and what is not. This means providing feedback on positive as well as negative behaviours. Consequences of unacceptable behaviours do not necessarily have to entail an unpleasant reaction or confrontation but could just consist of walking away from the person or ignoring them.

Rewards
Rewards for positive behaviour should be given immediately after, so that the person can learn to associate the reward with their behaviour. Rewards can be more effective if they are implemented as part of a contract (e.g. if you go for a walk today, you can have your favourite dish for dinner). It may help to record positive behaviour in a chart so that the person can see the benefits of their good behaviour. Rewards can take any form, such as a gift, a card or simply positive feedback, depending on what the person responds to best.

Negative feedback
As with rewards, negative feedback should be given immediately following the behaviour. Negative feedback is more effective if it is used in conjunction with a system of reward, otherwise it may trigger more behavioural problems. Examples of negative feedback are turning away, using simple gestures such as thumbs down, or strong verbal reprimands to let the person know their behaviour is not socially appropriate. 

Monitoring Behavioural Problems

As with all interventions, it is important to monitor how effective strategies are and to modify them if appropriate. An easy way to check if strategies are working is to note down how often behaviours occur and track whether they have decreased since the start of an intervention.