• Peter Gathercole

18 Must use strategies to use in reducing challenging behaviour in dementia

What is challenging behaviour?

The term "challenging behaviour" has been used to refer to the "difficult" or "problem" behaviours which may be shown by individuals. Such behaviours include aggression (e.g, hitting, kicking, biting), destruction (e.g, ripping clothes, breaking windows, throwing objects), self-injury (e.g, head banging, self-biting, skin picking), tantrums and many other behaviours (e.g. running away, eating inedible objects, rocking or other stereotyped movements). Characteristically, challenging behaviour puts the safety of the person or others in some jeopardy or has a significant impact on the person's or other people's quality of life.

In general, challenging behaviour is rather more common in people with dementia, though the pattern varies considerably depending on the type of behaviour being considered and the age and type of dementia of the person.

Why does challenging behaviour happen?

The first point to make is that there is no simple answer to this question. However it is helpful to remember, that most people without dementia display lots of challenging behaviour as the disease progresses.

In general then, many cases of challenging behaviour appear to be effective ways for a person with dementia to control what is going on around them. This may reflect their lack of more usual methods of control and the more unusual nature of the environments to which they are exposed.

While the above is a generally accepted account of why challenging behaviour occurs we should always consider, especially if the behaviour has just arisen or worsened, the possibility that it reflects some kind of biological or emotional disturbance. People may bang their heads because their ear aches or hit out because they slept poorly the previous night. Understanding the variation in a person's behaviour that challenges is often a key to promoting positive change.

What can be done to reduce the behaviour?

Unfortunately, challenging behaviour is not generally like an infection which can be treated by a short-term course of antibiotics. In many cases there will be no "magic bullets", change may take some time (especially where the behaviour is well established), will almost certainly require changes in the way other people behave and may be very susceptible to relapse. Having said all this, there is a great deal that can be done to prevent and treat challenging behaviour.

The goal of prevention is a worthwhile but elusive one. Where challenging behaviour arises from a medical condition, a sensory impairment or similar, the more such conditions can be remedied the better. On an everyday basis, carers can try to ensure that the person has what they need when they need it - help, attention, food, drink, preferred activities and so on. It is very important, however, that people are also given the opportunities and the skills to get things for themselves or to ask for them rather than them always being available "on a plate". Without the opportunities of exerting such control, people with dementia will be in much poorer positions when they get into situations (as they inevitably will) where they are expected to fend for themselves and speak up for themselves more. One of the keys to prevention (and also to treatment) is therefore to emphasise the development of communication and independence.

If prevention has failed, early intervention is the next best thing. Staff often complain that their attempts to get help early on are met with bland reassurance rather than practical assistance. Staff should, therefore, take the person's challenging behaviour seriously especially if it is of a kind not usually found in a person without a dementia. What can staff do? Getting help is obviously important but where that is not available or slow to arrive staff should consider the following actions:

  • Treat the behaviour as evidence of a previously undetected problem. Is the person in pain? Or bored? Or being asked to do things they find difficult? Or trying to "tell" you something? And so on.

  • Try to check things out for yourself. If you change something does that stop the behaviour? Can you teach the person to tell you what they want without challenging behaviour?

  • Keep some sort of record of when the behaviour happens and the things you have done to try to figure out what's going on. In a year or two's time you'll find that it's very difficult to remember the details.

  • If (and only if) it is safe to do so then " ignore" the behaviour (don't comment on it, don't tell the person off, appear not to notice it) and change the situation (distract, divert) as quickly as you can. If distraction or diversion are impossible you may have to leave the person on their own but you need to be sure that the situation is safe and be able to cope with the behaviour possibly continuing for some time before it stops.

  • If it is not safe to ignore the behaviour respond as calmly and blandly as possible to prevent the person hurting themselves or others.

  • If you do have to respond, better to respond quickly than slowly - otherwise you are teaching the person to be more persistent.

  • Challenging behaviour can be an emotional experience - you may feel very angry with the person or very depressed about their behaviour.

  • Don't be ashamed of this, don't bottle it up and don't take it out on others! Instead, talk about it with anyone who will listen and understand.

18 Strategies to reduce challenging behaviour

1) Structuring: - having worked hard to establish consistent and predictable environments it is important that these do not collapse in the face of challenging behaviour. This has negative consequences for workers, other service users and the perpetrator. If the structure is fragile this conveys a message of ‘out of control’, which can only escalate challenging behaviour.

2) Active listening: - the service user has valid feelings which are important and you should be concerned if they are distressed. Active listening skills are important to hear what the person is saying, time, environment, right place, eye contact, positioning, open statements etc.

3) Relating: - the quality of the relationship that has been built is central to the ability of supporting a person’s distress, frustration and anger. This determines levels of respect trust and influence over behaviour (link as an essential part of any environmental analysis which should identify the type of relationships that are built in the care environment).

4) Redirection/Diversion: - (again a consideration which should form part of any environmental analysis, what are the potential hot spot? What alternatives are available)? Redirect the service user or group, change the activity or environment, suggest something that you know will be more enjoyable and replace the behaviour with something positive.

5) Teaching: - help service users learn from experience, (principles of crisis intervention) use everyday experiences, situation, crisis points as an opportunity for growth and learning. New ways of coping are best learned through experience and process.

6) Humour: - an injection of humour can often release the tension out of a situation, divert attention or provide the person with an escape route. This is not always appropriate, does not work with anger and aggression and must never be at the expense of the person.

7) Injection of Affection/Praise (Hypodermic Affection): - method for increasing self-esteem, people respond better to praise and messages as to what they do well and can achieve as opposed to negatives. Behaviour often comes from insecurity, fear and anxiety. If you consistently reward service-user with respect and praise (1 in 10 principle, one negative to ten positives) there is increased chance of reducing the level of difficult behaviour.

8) Past Strengths/Appeal: - reminding the person that you and others are also people who have needs, which are also important. Focus centres on how well the person has dealt with similar situations in the past, particularly drawing out the positives as to how they managed their behaviour.

9) Prompting/Signalling: - the establishment of non-verbal forms of communication to assist the management of behaviour. The signal technique lets the person know that their actions are noted. This approach can signal approval or disapproval and fits well with injections of affection ‘through for example, a smile.

10) Planned Ignoring: - requires teamwork and commitment, not everyone can tolerate the behaviour without eventually giving in or punishing the service user. Ignoring the behaviour can render it ineffective and it will reduce until it stops. The principle is to make the behaviour extinct through ignoring. The initial response to ignoring behaviour is for the person to escalate it. This requires further ignoring or intermittent reinforcement. It is crucial to assess the risks attached to ignoring behaviour and all involved workers need to be aware of what the appropriate or substitute behaviour is to be reinforced. Ignoring negative behaviours and rewarding positive ones ensures the person receives reinforcement when displaying appropriate behaviour patterns.

11) Permitting: - allowing the behaviour to take place. Giving permission for disruptive activity often reduces the attraction of it. If no one is in danger and no damage is likely, it may be better to give permission for the behaviour to take place.

12) Acceptance/Interpretation: - works well with relating approaches above, verbalising the behaviour helps control aggressive feelings and expressing the source of anger helps externalise emotion and reduces its intensity. This helps the person to sort out confusion and redress poor processing of information.

13) Restructuring: - dealing with deteriorating relationships by a change of place, activity or people. This requires an assessment of the negative dynamics and making a decision to change the parameters, membership or location of an activity.

14) Removal of Person/Audience: - this should be by request and agreement. Creating space for a person, changing the environment, removing the crisis trigger can be achieved by moving the person. If they will not it may be possible to remove the audience. Behaviour is often supported by an audience or through the fear of losing face. The removal of an audience changes the environment, offers an escape route and creates space to calm down. It may be necessary to involve several team members to remove the audience.

15) Leave It Option: - wrong person, wrong place, need to hand over to another worker.

16) Stimulus Change: - do something unusual, unexpected, useful for low level behaviours, need to consider client group as not suitable in areas of learning disabilities for example.

17) Praise/Rewards: - using rewards as a means of enforcing positive behaviour patterns. It is important the person does not become reliant on a form of reward that will not be replicated in other settings. Rewards can be used as a short term means to cementing new patterns of behaviour.

18) Silence: - service user can feel companionship, comforted by someone being there. When working in the field of learning disabilities this can be useful in giving people time to comprehend what has been said, formulate a response, take information in.