Challenging Behaviour (CB) 2:

1. Challenging Behaviour (CB) 2: Assessment

2. Functional Analysis • As highlighted in the Introduction presentation, ‘challenging behaviour’ can be a very subjective issue. • Therefore, we need to get very detailed, good quality, more scientific data to fully understand the behaviour. • A ‘FUNCTIONAL ANALYSIS’ is an approach that helps us to UNDERSTANDWHY a CB is happening, by identifying what the behaviour is COMMUNICATING. • This will then help us to develop the most effective, efficient and person-centred interventions by adapting aspects of the person’s environment, interactions or behaviours.

3. Functional Analysis • The first place to start with an assessment is to summarise the person’s relevant history: • Known medical/physical issues – e.g. type of stroke, diabetes, arthritis, visual problems, hearing difficulty, cardiac problems etc. • Mental health – history of depression, anxiety, psychosis etc. • Everyday functioning & current homelife– e.g. lives in 2 bedroom house with husband and pet dog, does all domestic chores & shopping independently, manages own finances, no known cognitive problems, some memory problems over past 2 years. • Lifestyle & hobbies/interests – plays golf 2xweek, enjoys regular city breaks, enthusiastic gardener, regular gym user, goes out with friends for lunch every Saturday etc. • Psychosocial (education, relationships, ‘personality’) – e.g. left school with 8 ‘O’ levels, large extended family with close relationship with cousin X, very outgoing and sociable and always willing to help anyone. • Occupational history.

4. Functional Analysis - data • If we consider the WHAT, WHEN, WHO & WHERE, we can start to work out the WHY– which will direct our interventions. • This will usually involve collecting very detailed information about: • WHATthe behaviour looks like (detailed description) • WHENis it happening: Date, time, duration • WHOdoes it involve: Staff, patients, family, friends, cleaner etc. • WHEREdoes it happen: Location – be specific e.g. corner in bathroom nearest the door; red chair in sitting room

5. Functional Analysis • Sometimes we can quickly identify a pattern of behaviour, without having to start a detailed recording schedule. • For example, ‘Jean’ may only exhibit CB (e.g. ‘agitation’, ‘shouting out’) when she wakes up in the early hours. It may quickly be established that she is disorientated when she wakes at this time, because she has known visual and cognitive problems and becomes frightened - wanting some reassurance or social contact to reduce anxiety. • Or, ‘John’ may become noticeably quiet and not eat after family have visited, although he is interactive when the family are present. It may be that he feels very sad and lonely when family have left, particularly as his homelife is very family orientated and he spent a lot of his time since retiring looking after his grandchildren and arranging outings for his local Social Club- he may feel a greater sense of loss and isolation which may also be exacerbated if he is on a side ward, away from other people.

6. Functional Analysis - ABC Sometimes, we may not be able to work out what a person’s CB is communicating so easily - so we are not able to effectively respond to help them. Or, we may think that we have a good idea why a person is exhibiting CB, but our interventions don’t seem to help. We may then have to get much more detailed and objective information about the context in which the behaviour occurs.

7. Functional Analysis - ABC • You will need to identify the CB in specific terms: • E.g. ‘constantly pressing buzzer to ask for toilet’. • Rather than just ‘Keeps wanting staff’. • You will also want to consider how often you need to record the CB: • If behaviours are constant or very frequent it may be better to record the information for a set time (e.g. in 10 or 20 minute episodes), several time throughout the day (or night). This will allow you to see if the behaviour is better or worse at particular times and this may also give an indication as to the WHY. • If the behaviour is less frequent (e.g. 2 or 3 times a day), then it may be better to just record your information every time the behaviour occurs. • When you have 5 or so recorded episodes or events, you can start to have a look at your data to look for patterns and identify the WHY? • Also, make a mental note of when the behaviours DO NOT HAPPEN (e.g. when having visitors, after a good night’s sleep).

8. Functional Analysis - ABC • We usually use ‘ABC’ charts (see examples in ‘Toolbox’) to document these details every time the ‘target’ CB occurs. This builds up the data over time, until we have enough information to start to identify specific patterns. From that, we have a better chance of identifying the FUNCTION (i.e. communication) of the behaviour.

9. Functional Analysis - ABC • The ‘ABC’ stands for: • Antecedent: • What was happening just before the CB occurred? • Again, thinking about the WHERE, WHO, WHEN • Behaviour: • Note observations, not generalisations! • E.g. Punched x 2, spitting, shouting threats to kick, shouting for staff, throwing buzzer at staff, throwing buzzer on floor, sitting and refusing to??? etc. • NOT just noting ‘aggressive’ or ‘unco-operative’ or ‘withdrawn’. • Consequences e.g.: • What happens following the behaviour? • Does anything change as a consequence? • How does the situation resolve?

10. ABC Chart Example – unusual pain complaints – ‘Anna’

11. Summary of Presentations 1 & 2 • Challenging behaviours are often communications about a person’s thoughts, feelings and experiences. • Challenging behaviours may develop from a combination of a person’s medical condition, their environment, their psychological/emotional state, previous experiences and medication. • Although they can seem to be random events, careful recording of the behaviours can often uncover WHAT the behaviour is trying to tell us. • The final presentation in the Challenging Behaviour Module will focus upon interventions. • Thank you for your interest.