Challenging behaviours are common after a brain injury. They can be caused by a range of factors outside of the control of the brain-injured person and can be an attempt to communicate unmet needs. Establishing a considerate care environment can help manage these behaviours.

 

What is challenging behaviour?

The majority of people who sustain moderate or severe traumatic brain injury have chronic neurobehavioral sequelae, including cognitive deficits, changes in personality and increased rates of psychiatric illness. [1]

A wide range of emotional and behavioural changes are common, including disinhibition, impulsivity, irritability, frustration, aggression, apathy, egocentricity, emotional lability, depression and anxiety. [2]

Examples of challenging behaviour include verbal abuse, shouting/swearing, physical aggression (including grabbing, biting, scratching, pinching, poking, hair pulling, punching, kicking and slapping), socially unacceptable behaviour, spitting, destruction of property, self-injurious behaviour, pulling tubes and restraints, wandering, sexually inappropriate behaviour, and behaviours that prevent necessary care interventions being carried out.

In the context of brain injury, “challenging behaviours” are considered to be 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
  • prevent the person from accessing a range of normal social and valued activities
  • prevent the person from accessing necessary medical, personal or social care
  • prevent the person from accessing therapeutic activities, engaging and progressing in the rehabilitation process, and
  • may lead to breakdown of a residential placement or affect the person’s ability to live in their own home. [3]

Challenging behaviours can arise from a complex range of factors outside the control of the brain-injured person. [4] Significant contributing factors can include:

  • personal, social, cultural and educational background
  • medical history, including substance misuse
    • discomfort and pain
    • anxiety, fear and distress
    • environmental factors
    • cognitive and communicative impairments
    • care tasks, including intimate procedures
    • increased confusion caused by sedative medication
    • psychological and psychiatric difficulties
    • seizure activity leading to confusion, potentially resulting in agitation/aggression, and
    • the approach adopted by those providing support, treatment and care.

 

Supporting the brain-injured person

Challenging behaviours are often a manifestation of a person’s distress and an attempt by the person to communicate their unmet needs. [5] They may be an attempt to secure resources, seek reassurance, regulate emotions, avoid demands, or escape threats (both ‘real’ and perceived).

Preventing challenging behaviour is concerned with understanding the reasons for a person’s distress by recognising their vulnerability, anticipating needs and designing care accordingly. [6]

The National Institute for Health and Care Excellence (NICE) guideline for challenging behaviour [7] recommends developing a written behaviour support plan that should:

  • identify proactive strategies designed to improve the person’s quality of life and remove the conditions likely to promote behaviour that challenges, including changing the environment
  • identify adaptations to a person’s environment and routine, and strategies to help them develop an alternative behaviour to achieve the function of the behaviour that challenges by developing a new skill
  • identify preventive strategies to calm the person when they begin to show early signs of distress, and
  • identify reactive strategies to manage any behaviours that are not preventable if a person’s agitation escalates and there is a significant risk of harm to them or others.

 

Adapting the care environment

Anyone who has experienced an admission to hospital is likely to be familiar with the stressful nature of the care environment. Most inpatient wards are busy, noisy, hot, disruptive and unpredictable. Constant alarms, frequent checks at irregular waking hours and disturbances from other patients are commonplace, even in specialist neuro-behavioural units.

The following environmental factors can contribute to the level of agitation a patient with challenging behaviour can experience:

  • restrictive environments, including being confined to one area and restrictive visiting hours
  • environments with little or too much sensory stimulation, and those with low engagement levels
  • developmentally inappropriate environments
  • environments where disrespectful social relationships and poor communication are typical or where staff do not have the capacity or resources to respond to people’s needs, and
  • changes to the person’s environment (for example, significant staff changes or moving to a new care setting). [8]

The King’s Fund’s ‘Enhancing the Healing Environment’ (EHE) programme has shown that relatively minor changes to the environment can reduce patient anxiety and incidents of challenging behaviour.

The programme, funded by the Department of Health, worked on a range of projects to make hospital environments less alienating for people with cognitive problems.

Putting patients at the heart of design, the programme challenged current thinking and attitudes towards the delivery of care, while also highlighting the important role that the physical environment can play in supporting innovation in service delivery and in improving the patient experience.

The overarching design principles of the EHE programme and an environmental audit tool can be found here: https://www.kingsfund.org.uk/insight-and-analysis/projects/enhancing-healing-environment

Adapting the care environment to make it less crowded, improve lighting, avoid temperature fluctuation, make it more comfortable, reduce excessive noise, consider the impact of electronic alarms, avoid excessive bed moves, strive for consistency of staff and support staff to anticipate needs, can have a significant impact on reducing levels of agitation for brain injured patients, and in turn support behaviours that challenge.

The consequences of not supporting challenging behaviour can be devastating for the brain-injured person, resulting in an overreliance on anti-psychotic medication, seclusion and physical interventions. [9]

Providing a space for healing for the brain-injured person is painless by comparison. 

 

 

The authors are Hayley Symington and Joanne Lockwood‑Smith, a nurse consultant in major trauma at Imperial College Healthcare Trust, and it was first published in the NR Times Yearbook 2026: Neuro Rehab Times Yearbook 2026 by Andrew Mernin.

 

Reference sources 

Key Contacts

See all people