Transcript Some proactive strategies are naturally implemented as

Challenging
Behaviour 3:
Interventions
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 selfstimulation (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 selfstimulation, 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!