charts used by the NCBT to collect descriptive information from carers about the problematic behaviours. The first scale is a standard ABC behavioural chart, placing particular emphasis on recording clients’ emotions.
Figure 2.1 Example of a behavioural chart incorporating an ABC analysis together with elements of the Newcastle approach
Figure 2.2 describes a recent development that attempts to get staff to empathise with the beliefs of the client. The front page of the latter document has the following instructions:
Instructions for behavioural grid
Step 1: Identify the type of challenging behaviour (CB).
Step 2: Provide details about the CB incident; do this in two stages. First, give information about the CB, then include details about how other people reacted to it and any consequences.
Client’s CB → Others’ reactions to CB and consequences
Step 3: Use the ‘Tables of Causes’ [as in Tables 2.1–2.6] to identify reasons for the CBs.
Step 4: This step involves you imagining yourself in the position of the client. So try to guess what the client might’ve been thinking, and how these thoughts and beliefs led to the CB.
Step 5: Use your knowledge of both the client and the setting to problem solve the best way to deal with the CB.
| Type of challenging behaviours | Description of challenging behaviours, including carers’ reactions | Causes of the CB | Person’s thoughts that triggered CB | Potential solutions | |
| CB | Reaction of others to the CB and the consequences | ||||
| Type of challenging behaviours | Description of challenging behaviours, including carers’ reactions | Causes of the CB | Person’s thoughts that triggered CB | Potential solutions | |
| CB | Reaction of others to the CB and the consequences | ||||
| Aggression | Peter put his hand on Mary’s shoulder and asked her to sit next to him. | Nurse told Peter to leave Mary and pulled his hand from her shoulder. After this Peter hit the nurse in the mouth. | Owing to Peter misidentifying Mary as his wife due to his dementia, he is annoyed that she does not want to spend time with him. When the nurse takes his hand off Mary, Peter gets angry that someone else is interfering. | This is my wife and she should be doing what I tell her to do. And when nurse takes Peter’s hand away… Get off me, and keep out of my business with my wife. | 1. Currently Mary looks like his wife. So ask the hairdresser to colour her hair and change the style. 2. Bring in photographs of his wife, and continually orientate Peter to the picture. 3. Distract Peter e.g. ask him to help you unscrew top off a jar, and remove Mary from scene while he is doing this. |
Figure 2.2 Challenging behaviour grid, incorporating carer reaction and beliefs (plus worked example)
| Table 2.9 Frontal lobe functions | |
| Difficulties | Practical description of difficulty |
| Perseveration | Repeating actions and statements over and over again. |
| Unable to inhibit responses | Unable to control aggressive or sexual actions/statements that would normally be out of character. |
| Saying things to hurt other’s feelings | Making unkind comments about others which can serve to provoke or upset them. |
| Impulsive actions and emotions | Suddenly doing something dangerous or risky – ‘out of the blue’. Sudden outbursts of emotion. |
| Poor short-term/working memory | Unable to correctly remember things done during the present day (e.g. breakfast, activities, etc.). |
| Recognition of objects, but unaware how to use them | Able to name an object, but unable to demonstrate its use (e.g. able to name a fork, but not aware how to use it). |
| Overly fixated on people or activities | Repeatedly paying attention, talking about or touching things (people, objects). Repetitive actions or activities. |
| Poor at making decisions | Unable to make choices, or decisions about what to do next (e.g. the person can’t decide what he wants to wear or is unable to choose his food at meal times). |
| Poor planning | Unable to work out how to tackle a problem. For example, when a difficulty arises the client doesn’t know where to begin, or can’t grasp the nature of the problems (e.g. failing to move items off a table, before putting new ones on; doesn’t recognise it would be helpful to write-out a shopping list prior to going shopping). |
| Poor sequencing | Unable to carry out actions in a logical sequence (e.g. unable to dress themselves in a logical order, or when toileting tends to open bowels prior to removing underwear). |
| Concrete thinking | Unable to think in an abstract way. Conversations tend to be interpreted in an overly direct manner (If told ‘it will all come out in the wash’, he/she thinks this refers to washing clothes). |
| Confabulation | Prone to giving stories and/or explanations in order to fill in gaps in his/her memory. |
| Lack of insight | Unaware of his current difficulties and limitations. Not being aware of the risks associated with these limitations (e.g. failing to appreciate he would not be able to live by himself at home). |
| Poor concentration | Unable to concentrate on anything for an extended period of time (e.g. watching TV, reading). Client’s focus tends to move quickly on to something else. |
| Distractibility | Easily distracted by things going on in the environment. When undertaking a task will lose interest in the task if interrupted by someone or something (e.g. a sound). |
| Apathy | Emotionally unresponsive, even when being provoked. |
| Euphoria | Overly enthusiastic, and/or inappropriately laughing out loud. |
Table Key: Item is rated on 1–5 scale (not like person–totally like person).
| Table 2.10 Some of the potential causal factors that are screened at referral | ||
| Key area | Type of problem | Example of problem which may be causal factor in BC |
| Age related issues | Sensory difficulties | Sight, hearing difficulties |
| Pain | Arthritis, dental pain | |
| Physiological and physical problems | Delerium | Confusion |
| Constipation | Discomfort, problematic gait, irritability | |
| Seizures | Confusion | |
| Vascular events | Sudden deterioration in skills | |
| Infections | UTI, cellulitis | |
| Diabetes | Variable levels of insight/performance | |
| Cancer | Brain metastases | |
| Thyroid | Hyper (agitated), hypo (confused) | |
| Mental health problems | Psychosis | Hallucinations, delusions |
| Depression | Irritability, labile, sleep problems | |
| Anxiety | Reassurance seeking | |
| Other | OCD, social phobia, trauma | |
| Medication | Anti-psychotics | Confusion |
| Benzodiazepines | Over-sedation | |
| Parkinson’s meds | Hypersexuality | |
| Pain
| ||
