How do you manage sudden or escalating challenging behaviour after brain injury, or any time?
Damage to the brain, for example the frontal lobe, can sometimes cause changes in behaviour after brain injury.
Sometimes this results in behaviour that challenges supporters and people around. It can also result in behaviour that is unpredictable.
Even with an agreed behaviour plan in place; sudden, explosive or escalating behaviour can still occur. This will often need immediate support and management from family, supporters, or people who are close by.
It can be difficult to respond quickly and effectively when
- you are taken aback by the behaviour,
- you are in a public space,
- it is a behaviour you find difficult to tolerate
- it is something you have not managed before.
Responding To Immediate Challenging Behaviours
When you are with a person who has unpredictable challenging behaviours, the likelihood of needing a strategy ‘on the run’ to call on in emergency situations is high. Being prepared is important. A C O R N is a simple starting point:
Alert
Calm
Open
Respectful
Non-threatening
A.C.O.R.N. is just one way to help you to respond when you find yourself in a situation that is difficult to manage. This is not a total solution. It does not replace the agreed behaviour management strategies; it supplements these when emergencies arise.
An Example Situation:
Two young men,‘Dave’ a support worker, and ‘Jason’ a young man in his late adolescence. Jason was a very social, fun-loving, engaging man, who could have sudden, unpredictable, and destructive behaviours after brain injury.
Dave and Jason were walking in a city park. Dave was walking close by Jason, observing who was around, as the two strolled around the park chatting amiably. Suddenly a dog ran across their path. Jason repeatedly kicked at the dog as it ran around his feet. When Dave suggested he not do this, Jason became angry, verbally abusive and kept kicking wildly at the dog. Passers-by were commenting and staring. Dave calmly talked to Jason and coaxed him back to the car to return home.
How would you manage this, or other sudden challenging behaviour?
A C O R N in Action – When Challenging Behaviour Happens
What follows is a guide. While some possible actions are included please make it your own:
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- add your own strategies for each
- you might develop your own acronym or strategy for responding.
- and it would be great to share any additional strategies you have in the Comments below.
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Whatever your response, remember always to think about strengths based approaches – simply this means a response that builds on strengths a person has, building skills, and reinforcing the positive rather than using punishment.
Alert
Have a keen regard for physical safety: the person with brain injury, yourself and others.
Take notice of the physical situation you are in e.g. where you are in relation to the person, what is the layout of environment, where are other people placed.
Know how and when to give the person space or to leave (with, or without the person)- if this is the safe.
Know who to call, and how to call for assistance.
Recognise signs of behaviour escalating and review your approach.
Dave had been given training and information on triggers for Jason’s challenging behaviour and agreed behaviour strategies were in place.
Dave had chosen the park because it was generally quiet. He had been close by Jason, monitoring Jason’s response to the people around them, which had been social and friendly. Dave had not known that dogs would be a problem for Jason.
After the incident Dave immediately checked the surroundings to see who the dog owner was, there was no-one obviously in charge of the dog. He chose to stay close to Jason and guide him back to the car immediately.
Calm
Speak and act in a calm manner e.g. ensure your voice is calm, respectful.
Convey firm and honest expectations that are realistic and can be delivered. Do not promise something you are not going to follow through on.
Try not to take anything said or done personally – it is the brain injury talking.
Keep your movements gentle, normal, and respectful. Try not to rush, or make panicked movements.
Model the behaviour you want to see in the other person (both community members and the person with brain injury).
Recognise and manage your own embarrassment or social discomfort.
Distraction can be a great tool: change the subject, move the person away, engage them in something else.
Do not confront or try to negotiate when a person is angry or upset. Wait till settled and calm.
Be aware of the affect of your own body language – are you reflecting anger, fear, lack of control?
Communicate with any other people involved and work to ensure everyone remains calm.
Despite a sudden challenging circumstance Dave maintained his composure and showed no reaction. He spoke calmly and quietly telling Jason what they were going to do next. He acted calmly but assertively to guide Jason back to the car.
Both men sat in the car and quietly talked for a short time about Jason’s football team. Jason and Dave both calmed down and Dave ascertained it was safe to drive back to the facility where Jason lived.
Openness
Work to ensure there are no losers. Create win-win solutions wherever possible.
Remain open to new solutions and possibilities.
Seek to fully understand the other person’s view (this is not the same as agreeing).
Ensure your body language and position conveys willingness to work together, openness and respect.
Acknowledge and work within your own skills and do not be afraid to seek assistance.
This incident came out without warning and with no previous incidence of this kind. He did not chastise Jason at the time. He explained each step he was taking.
On return Dave sought his supervisor as soon as Jason was safely home to explain and talk through what had happened. They agreed this new trigger needed to be considered in the plan for Jason’s challenging behaviour.
Respectful
Listen carefully to the person and acknowledge you have heard them.
Treat the person as you would treat anyone else, but be aware and prepared that they may not behave the same as everyone else.
Speak in a way that the person clearly understands, but is not demeaned.
Ensure the person’s dignity is maintained particularly if out in public or others are around.
Do not belittle or minimize the problem.
Let the person explain in full their issues and emotions if they are able to and wish to.
Find common ground and points of agreement when negotiating.
Once the situation is past, talk to the person about the affect their behaviour has, and offer alternatives.
At the time of the incident, (though he was taken aback) Dave continued to have clear calm adult conversation with Jason.
Dave made it clear what steps he expected of Jason without anger or blame. Dave did not speak about the incident with Jason until much later when Jason was calm and back home.
The treating therapists followed up with Dave and Jason on his return once he was calm. Everyone involved then worked with him on new behaviour strategies to ensure safety of everyone when Jason was out in the community.
Non threatening
Try not to argue/blame/give orders/lecture/defend another
Do not touch without permission
Where possible and appropriate sit with the person (at the same level)
Be yourself and be natural
Try not to take the behaviour personally
Use humour – but be careful about respect and cultural issues
Maintain eye contact if this is culturally appropriate
As soon as you can remove the person from the situation – or remove the trigger.
If you can and it is safe to do so – support other people involved to remain calm, non-judgemental and non-threatening.
Do not try and discuss the situation with the person straight away. Wait till everyone has calmed down.
Dave continued to talk and banter in the same way they always did.
He maintained direct eye contact as he explained what they were going to do next.
While he tried to encourage the dog to leave, he decided not try and physically intervene to restrain Jason but steer him away from the dog.
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