Understanding challenging behaviour

‘Challenging behaviour’ refers to any non-verbal, verbal or physical behaviour by a patient which makes it difficult to perform clinical tasks and/or poses a safety risk. It can describe actions, but can also include non-compliance, particularly if staff need to intervene to deliver treatment or care.

There are different types of challenging behaviour:

Non-verbal challenging behaviour may include…wandering, pacing, cornering, intimidating facial expressions

Verbal challenging behaviour may include…shouting, swearing, racist, sexist or offensive speech

Physical challenging behaviour may include…scratching, biting, slapping, inappropriate touching, self harm, spitting, punching, hitting furniture

You can view this table on types of challenging behaviour for more details.

Patients who display challenging behaviour often have some degree of cognitive impairment, either long term (e.g. due to dementia, a mental health condition or learning disability) or short term (e.g. due to delirium, head injury, or drug/alcohol intoxication).

Why does it happen?

There is always a cause of clinically related challenging behaviour, even if it is not evident to staff at the time. Challenging behaviour is often an expression of distress or an attempt by the person to communicate an unmet need. Identifying unmet needs and other reasons for challenging behaviour in order to prevent distress should reduce the likelihood of unforeseen events. It is vital that staff take care in determining whether a patient’s behaviour is a result of an illness or injury which requires urgent attention.

The reasons are usually complex but can be classified as follows:

1) Physical factors

Some features of a person’s clinical condition could make them more likely to be distressed, and other physical needs may be manifested through challenging behaviours, especially if they cannot be communicated. For example:

    • delirium (a short-term confusional state or worsening of pre-existing confusion, due to a physical cause)
    • sensory impairment
    • pain or other unpleasant symptoms
    • drug or alcohol withdrawal
    • after-effects of anaesthetic
    • hunger or thirst
    • needing the toilet
    • poor sleep.

2) Cognitive factors

These may relate to:

    • the person’s inability to process new information, explanations or instructions
    • loss of inhibitions
    • poor judgment and planning
    • difficulty with communication and inability to articulate needs
    • memory loss
    • disorientation
    • reduced spatial awareness
    • loss of insight.

3) Psychological/emotional factors

These may be for example:

    • feelings of anxiety or powerlessness
    • anger
    • social isolation
    • depression
    • delusions, especially where people feel threatened and react defensively
    • personality disorders which may cause difficulty anticipating the consequences of their actions and acute distress
    • mania
    • hallucinations
    • suicidal tendencies.

4) Social/environment

Certain social and environmental factors can provoke challenging behaviour, especially if they are prolonged or interfere with someone’s routine or sleep, e.g.:

    • noise
    • bright lights
    • uncomfortable temperatures
    • overcrowding
    • overstimulation
    • inactivity and boredom.

Additionally, a lack of understanding of an individual’s culture and related behaviour can lead to frustration and agitation.

You can view this table on the reasons for challenging behaviour for more details.

Identifying patterns

Searching for patterns to challenging behaviour can help staff predict when challenging behaviour is more likely, to plan and prepare, and to prevent it. For example, challenging behaviour in many people has a tendency to occur during certain interventions, such as during care tasks, administration of medication, or at particular times of day, such as at mealtimes.

Knowing about triggers

Triggers are environmental, situational or physical factors that set off an individual’s challenging behaviour. These factors vary depending on the individual, but they may include the care environment, interventions, activities, objects, thoughts, feelings, pain or discomfort. For example, a person can become overwhelmed or distressed when a group of healthcare professionals undertake a care intervention in close proximity to them.

Once identified, many triggers can be avoided. That is why observing, identifying and documenting potential triggers can be the first part of a proactive strategy for minimising stressful or distressing situations.

Recognising precursors

Precursors are behaviours which often precede challenging episodes. They may be an obvious prelude to distressed or aggressive behaviour or they may just leave staff feeling uncomfortable. They may signpost the onset of challenging behaviour. Staff need to be aware of precursors and recognise them so they can effectively de-escalate a situation. Precursors to challenging behaviour are specific to individuals, so they can often be recognised from earlier episodes.

You may find this framework for explaining challenging behaviour helpful.

For further information on understanding challenging behaviour, please refer to the full guidance document.