Challenging Behaviour Cass Adamson May 2010

 “Culturally abnormal behaviour(s) of such an intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to seriously limit use of, or result in the person being denied access to, ordinary community facilities.”  Emerson, 1995, cited in Emerson, E (2001, 2nd edition): Challenging Behaviour: Analysis and intervention in people with learning disabilities. Cambridge University Press

Aims:  Explore CB: - Learning disabilities - Dementia - Violence/aggression  Difficult consultations - Frequent attenders - Medically unexplained illness

Learning Disability  Definition: - Impaired intelligence - Impaired social functioning - Onset before adulthood  3% children and 2% adults  RFs - age- multiple impairments - gender - communication difficulties

Case 1  Samantha is 20. Cerebral palsy with moderate learning disability. Poor verbal communication. Lives with her parents. Developed a new behaviour recently. Over the past 4 months, started to become very unsettled in the evenings and rocks agitatedly, shouts and sometimes bangs her head against the wall. Her parents are at a loss of what to do, as ‘we haven’t changed anything’.

 How do you assess the behaviour?

Challenging behaviour - aggression - self-injury - stereotyped - disruptive - destructive

 Functional assessment  Social attention  Tangibles  Escape  Sensory

 It emerged behaviour happened same time of day – after the evening meal. Family usually watches TV.  The family tried offering puddings and toys to no effect.

 It emerges that the behaviour started after her younger sister, Sophie, left to go to University. With reflection her parents recalled that Sophie used to sit with Samantha during Eastenders and that she would sometimes brush and style her hair.  Her Mum started brushing her hair and the behaviour stopped.

Case 2  Rob Turner is a 28 year old man with moderate learning disabilities. Lives alone with 24hr support.  You receive a request for a home visit to assess him for medication as he is having ‘frequent violent outbursts’.

 What do you do?

History  2 outbursts.  One last Tuesday – carer took jacket to Rob to take him to college. Rob moved away and groaned. Carer persisted and Rob lashed out. Carer told Rob they would not go out and Rob settled and went to sleep.  Following day, Rob took his coat to the carer. Carer said he would not take him out. Rob became angry and destroyed a piece of furniture.

Examination  Rob is settled.  He allows you to take his temperature and pulse, listen to his chest and palpate his abdomen.  NAD.  Do you prescribe a sedative or neuroleptic?  How do you find the cause?

 ABC chart

ABC chart  Name:  Day, Date and Time of Incident:  Definition of Behaviour:  Antecedent events  Provide a step by step description of exactly what you observed prior to the behaviour, or at the same time as the behaviour occurred.  1. Where was the person, and exactly what were they doing?  2. Was anyone else around, or had anyone just left?  3. Had a request been made of the person?  4. Had the person asked for, or did they want something to eat or drink?  5. Had the person asked for, or did they want a specific object or activity?  6. Had an activity just ended, or been cancelled?  7. Where were you and what were you doing?  8. How did the person’s mood appear, e.g. happy, sad, angry, withdrawn or distressed?  9. Did the person seem to be communicating anything through their behaviour

 Behaviour  Provide a step by step description of exactly what the person did, e.g. he ran out of the living room, stood in the kitchen doorway and punched his head with his right hand for approximately 1 minute.  Consequent events  Provide a step by step description of the exact events that occurred immediately after the behaviour.  1. Exactly how did you respond to the behaviour? Give a step-by-step description.  2. How did the person respond to your reaction to the behaviour?  3. Was there anyone else around who responded to, or showed a reaction to the behaviour?  4. Did the person’s behaviour result in them gaining anything they did not have before the behaviour was exhibited, e.g. attention from somebody

Using the chart:  Event 1:  A – Rob quieter than usual and resting.  B- Withdrawal, moved away from carer, groaned. Lashed out at carer afterwards. C – Carer put coat down and told Rob they were staying in. Rob settled quickly and slept.

 Event 2:  A – Rob appeared happy and usual self. Took his coat to carer. Carer said they would not go out.  B – Angry. Destructive.  C – Carer left him alone. Took a while to calm down.

 No further outbursts.  By using the chart, and with the carers knowledge of Rob the GP was able to deduce behaviour probably due to single episode of physical pain e.g. headache.

 Difficulty communicating  Difficulty in understanding - hearing loss more common in people with LD - abstract concepts, negatives and time concepts - interpret literally - state action desired first, first Communication

 Make every effort to communicate directly with person  Speak slowly and clearly  Give them time to respond  Use simple language  Ask open questions  Be honest  Change questions round if don’t understand or to check understanding.  Emphasise key words  Repeat as many times as needed

 Use longer appointment times  Consider first appt if pt agitated by waiting  Often don’t connect actions or events with illness  Use events they will understand when discussing time.  Ask pt to repeat before leaving  Document known gestures, symbols and signs etc  Use communication passport

Behaviour  Keep record of each behaviour  Define each behaviour  Early warning signs  Trigger factors  Consequences of behaviour  Construct reactive and proactive plans to deal with behaviour in future  Consistency

 LD is spectrum  Change behaviour often sign of physical illness  Common things are common - CRUD  Can have any medical problem that affects general population  Increased health problems Remember…

Dementia  Behavioural and psychological symptoms  High carer stress  PAID

Case 3  John Smith 78 yrs. Known dementia. Lives with his wife. Deteriorating.  Wanders day and night. Aggressive intermittently especially physical interactions. Incontinent urine evenings and night. Occasional faecal incontinence and manual evacuation. Poor appetite.  Wife struggling to cope.

 PMH – hypertension - dementia - dementia  DH – bendroflumethiazide 2.5mg od - haloperidol 5mg bd - haloperidol 5mg bd

 Options?

 Explaining to wife and pt the causes of problems and options available can help  Allow his wife to attend and discuss her problems and concerns  Day care  Social services  Carers for assistance ADLs  Contact Alzheimer’s society  Age concern for friend or sitter for pt  Carers UK  Respite care  Care home

Wandering  Walk with them, prevent getting lost  Teach them safe route  Sometimes it’s a phase  Let them if safe  Alarms  Contact details on the person in case gets lost  Can divert with another activity  If wander at night – safety clothing

Incontinence  May hide wet clothes or wrap faeces in paper and hide  If use inappropriate objects, remove  Toileting routines  Clear path  Sign or picture on door  Seat different colour to toilet  District nurse  Continence specialist  Physio/OT

Aggression  Approach slowly  Offer explanatory sentences  Try to identify reason

Repetitive questions  Showing more effective  Distraction techniques  Use names of people not ‘he’  Simple one point sentences  Say what you mean  Gestures often understood longer than language

Aggression and violence  Cause major injury  Require medical assistance  Require first aid only  Involve a threat, even if no physical Injury results  Involve verbal abuse  Involve non-verbal abuse  Involve other threatening behaviour

Reasons:  Work involves contact with range of people in difficult circumstances  Patients and their relatives may be anxious and worried  Some patients predisposed violence.

Risk factors  Working alone  Working after normal working hours  Working and travelling in the community  Handling valuables or medication  Providing or withholding services  Exercising authority  People who are emotionally or mentally unstable  People under the influence of drink or drugs  People under stress or scared

Risk assessment  Identify potential assailant  Exit strategy  Consider ‘weapons’  Visits  Consider high risk activities  Rapid development esp. drink, drugs or mental illness

Risk reduction:  Lighting  Wider reception desks  Enough seating for all those waiting  Prevent boredom  Keep people updated  Heavy or fixed fittings  Alarms

 Assess home visits  Use police escort  Avoid being alone  Reception staff first to encounter – train  Call for help  Barrier between you and person  Try not to escalate  Report incidents

Conflict resolution training  Training can increase ability to deal with verbal aggression, increase feeling safe  Basic training: - all staff  Basic training plus techniques to defuse, de-escalation, breakaway

Dealing with aggression  Stay Calm and Adopt an Assertive Approach.  Notice the Aggressor and Allow them to 'Let off Steam‘  Listen Actively  Do Not Reward Rudeness or Abuse  Do Not Bluff  Focus on the Story, not the Aggression

 NHS zero tolerance policy - patients do not have to be treated most local GP if history violence - can’t deny treatment life-threatening or severe mental health - can only remove from list usually after written warning unless exceptional

Three V’s of visiting:  Vet  Verify  Vigilance

References  ence_aggression.pdf ence_aggression.pdf ence_aggression.pdf  BMJ Careers 31/5/08 p185 Violent patients I.Torjeson  RCGP e-learning    Courses%20&%20Resources/Education%20Pu blications/Ed_Matters/Ed-no19.pdf Courses%20&%20Resources/Education%20Pu blications/Ed_Matters/Ed-no19.pdf Courses%20&%20Resources/Education%20Pu blications/Ed_Matters/Ed-no19.pdf   AIT 2(4) pp S.Iliffe, P.Jain, J.Wilcock. 

Case 1  Judy Brown 30yrs.  Attends every few weeks with ‘cystitis’ symptoms.  Seen various practice members. Some have sent MSUs, some treated, some both.  How do you manage?

 Most MSUs were negative.  Practice meeting – agree management plan all consistent with.  Agreed only treat if MSU positive.  Pt stopped attending frequently.

Case 2  Maggie Snowden 42 yrs.  Attends with back pain.  Has seen you weekly for 5 weeks with vague or minor symptoms.  Has had 21 appointments with other members past 9 months.  What do you do?

 Notes – frequent attending started 2 yrs ago.  She denies event at time, but appears emotional.  Later she admits her son was arrested at that time for drug dealing.  No close friends.  Learns to accept that her symptoms due to internalising.

Case 3  Lisa 18 yrs. Lives in residential home as severe LD.  Stays with aunt most weekends.  Carers aware of aggressive behaviour few days after returning.  Home visit not suspicious – request GP opinion.  What do you do?

 History and examination.  Simple blood tests - reveal hyperglycaemia  Emerges Aunt feeds sugary treats and she has hypoglycaemia after.