Aim: To understand behavioural difficulties (challenging behaviour), the contributory factors which may underpin these behaviours, how to identify them and how to support the person who presents with behavioural difficulties following brain injury.
Challenging behaviour is not easy to define. People have different levels of tolerance for 
behaviour; what is considered challenging for one person may not be for someone else. Behaviour which is perceived as acceptable in one circumstance may not be perceived as appropriate in others (e.g. a group of young males in the pub joking and swearing vs. the use of foul language used by an employee towards their boss). Therefore behaviour may be viewed as challenging if it is considered inappropriate to the situation.
Other behaviours are more easily recognised as challenging regardless of the context e.g. physical aggression. The use of the term ‘challenging behaviour’ often has derogatory connotations. However, in the context of brain injury, the term challenging behaviour should not be used in a pejorative sense. It is important that we do not ascribe ‘value judgements’ or apply unhelpful labels.
Following Acquired Brain Injury (ABI), challenging behaviours may at times appear extreme and difficult to manage for the people trying to support the person with ABI. The behaviour may have the opposite effect to that which the person intended. However, it should be recognised that the purpose of challenging behaviours may represent attempts by the person to communicate ‘normal’, everyday things, for example:
- Stress, anxiety and confusion.
- Difficulty coping with their situation (e.g. receiving care and/or medical/therapeutic interventions, being in a noisy, busy environment).
- Feeling overwhelmed.
- Feeling unwell or experiencing pain.
- Wanting to be left alone.
- Wanting to go home.
- Wanting something e.g. companionship, food, warmth, sex, money.
- Wanting control of their situation.
Challenging behaviour can arise at any time following brain injury. A range of behaviours are frequently seen during the period of post traumatic amnesia and the early stages of recovery. However, they may also develop many years after the brain injury. Challenging behaviours following brain injury can arise from a range of factors which are outwith the control of the brain injured person.
In the context of supporting individuals with ABI, challenging behaviours can be considered as those behaviours which:
- Are potentially harmful to the brain injured person or others.
- Cause damage to property.
- Cause offence/upset to others.
- Are highly disruptive to the environment in which the person resides.
- Prevents the person accessing a range of normal social and valued activities.
- Prevent the person accessing necessary medical, personal or social care.
- Prevent the person accessing therapeutic activities, engaging and progressing in the rehabilitation process.
- May lead to breakdown of a residential placement or affect the person’s ability to live in their own home.
Examples of challenging behaviour include: verbal abuse, shouting/swearing, physical aggression, socially unacceptable behaviour, spitting, destruction of property, self injurious behaviour, sexually inappropriate behaviour, behaviours which prevent necessary care interventions being carried out etc.
Challenging behaviour may be evaluated in the following ways:
- The nature of the behaviour.
- How often it occurs.
- The duration of each episode.
- The severity and associated risks.
Causes of Behavioural Difficulties after Brain Injury
Assessment of Behavioural Difficulties
How to Help the Person with Behavioural Difficulties