Strategies for Challenging Behaviors in Adult Day Health Care Settings

In the setting of an Adult Day Health Care program, the additional burden of challenging behavior puts a vulnerable population in increased jeopardy. Goldie Dersh, PhD, Vice President of Behavioral Health Services at Lighthouse Guild, stresses three principles for optimizing the management of challenging behaviors: identify, intervene and collaborate.

Identify: “Challenging behavior” has become the most accepted term for actions whose intensity, frequency or duration puts the emotional and physical safety of the person or others in jeopardy. The problematic behavior may have a genetic basis (e.g., self-injurious behavior in people with Lesch-Nyhan syndrome) or be caused by neurochemical or brain structure anomalies, or psychiatric disorders.

The relationship between the challenging behavior and diagnoses can be complicated, with psychiatric disorders, dementia and developmental disabilities all potentially affecting individuals singly or jointly. Mood disorders, psychotic disorders, personality disorders and cognitive disorders can lead to a variety of problematic behaviors, including tumultuous relationships, volatile behavior, oppositional behavior, physical aggression, generalized irritability, pacing or yelling, and even psychotic episodes with hallucinations or delusions.

Intervene: Dr. Dersh stresses that, ideally, assessments of behavior should begin before admission to an Adult Day Health Care program. Medical, social and psychiatric information should be collected, as well as reports from the individual, family and caregivers. An assessment plan will point to ways to reduce possible challenging behavior or lessen its effect. The provider should ask, “What motivates the person to engage in challenging behavior, and what does he or she want or need that might support a change in this behavior?” Challenging behavior can be triggered by the environment and social relationships, Dr. Dersh notes, so alleviating or removing those potential triggers will help. Teaching the person new skills and alternative behaviors will reduce episodes of challenging behavior.

Dr. Dersh also describes the ABC Chart method. An ABC Chart (which stands for Antecedents/Behavior/Consequences) assesses the challenging behavior. An Antecedents list includes physical, social, psychological and environmental events that preceded the behavior; the Behavior section describes the challenging event in detail; and the Consequences section takes a look at whatever positive or negative outcomes occurred for the person. Armed with this information, an understanding of the reason for the behavior can be formed. Cognitive behavioral plans, mood disorder behavioral plans and personality disorder behavioral plans all use this information to create effective interventions.

Collaborate: Success or failure often hinges on collaborative interaction between medical, behavioral and ancillary providers. After choosing an appropriate Adult Day Health Care program, collaboration is paramount. Dr. Dersh emphasizes teamwork and communication, which together help maintain clinical strategies to prevent or manage challenging behavior. Where warranted, a behavior alert should be created for a patient exhibiting problematic behavior, and in the event of a problem, everyone on the crisis team should know their roles. After an incident, the patient as well as the staff and family members need to be debriefed, and the patient’s medical status should be reevaluated.