Initial assessment and support for challenging behaviour in a person with developmental disability

It may take a number of consultations for a general practitioner (GP) to establish rapport and thoroughly assess a person with developmental disability who is exhibiting challenging behaviour. For advice on facilitating consultations, see General practice and emergency presentation of a person with developmental disability and Communicating with people with developmental disability.

Considerations when assessing and managing challenging behaviour in a person with developmental disability outlines considerations when assessing and managing challenging behaviour in a person with developmental disability. If a referral for behaviour support is needed, this assessment information will inform the development of a behaviour support plan.

Commonly missed causes of challenging behaviour in people with developmental disability are listed in Commonly missed causes of challenging behaviour in people with developmental disability.

Questions to guide taking a history of challenging behaviour in a person with developmental disability includes questions to guide taking a history of challenging behaviour.

Table 1. Considerations when assessing and managing challenging behaviour in a person with developmental disability
Safety
Assess the immediate safety of the person and those providing their support; consider if any urgent action is required to secure their safety—see Acute behavioural disturbance.
Consent
Establish consent and capacity to make decisions and identify the appropriate person to assist with any supported decision-making processes that might be needed.
Define and describe the behaviour
Define and describe the challenging behaviour so that others can recognise it when it occurs, respond appropriately and record data for monitoring—include the frequency, duration, setting and severity; see Questions to guide taking a history of challenging behaviour in a person with developmental disability and Defining the target behaviour.
Assessment
Consider why the person is exhibiting the behaviour, including what might they: be trying to communicate using the skills they have and in the best way they can, under the prevailing conditions need or want, not want or be protesting against be thinking or feeling when they exhibit the behaviour. Document findings and rationale for intervention in the person’s health record.
Medical and psychiatric assessment Examine the person for medical and psychiatric disorders; exclude commonly missed causes of challenging behaviour (Commonly missed causes of challenging behaviour in people with developmental disability). See also Principles of assessment of psychiatric disorders. If the person has difficulty tolerating a physical examination, see Investigations and procedures and Communicating with a person with developmental disability. Consider health problems that are common in people with development disability; see also Comprehensive health assessments.
Social and environmental assesment Consider the person’s social and environmental circumstances, including historical issues and any recent changes, such as: the important people in the person’s life (eg family, friends, peers, carers), and if the frequency or duration of contact with them has recently changed the important elements of the person’s usual routine (eg what they like and don’t like), if there have been recent changes, and if there is regular opportunity to do what makes them happy and to avoid what they dislike life events (eg transitions, loss, trauma) sensory issues (eg sensory deterioration or loss, altered thresholds) safety considerations (eg neglect, abuse and trauma)—it might be necessary that these are formally investigated.
Psychosocial and developmental assessment Consider the person’s stage of psychosocial development, their skills and support needs, including: communication preferences cause of disability (eg behavioural phenotype) usual behaviour, abilities and challenges NDIS plan and funded supports knowledge, expertise and attitudes of carers and support people.
Multidisciplinary assessment Refer the person for further assessment (eg by a psychologist, speech pathologist, physiotherapist or occupational therapist); see Facilitating a multidisciplinary approach to care.
Intervention
Develop strategies to meet the person’s immediate needs and, as best as possible, to meet these needs going forward. Consider interventions and refer if necessary, for example: behaviour support plan by an NDIS positive behaviour support practitioner occupational therapy to optimise function speech pathology to optimise communication pharmacological interventions, including review by a clinical pharmacist. Support the information needs of parents, carers and siblings, and consider any ongoing risk posed by the challenging behaviour. Parents, support people or siblings may benefit from referral for support and counselling.
Review
Regularly review the person and the impact of any intervention, including drug therapy; see Monitoring and reviewing strategies. Consider if recent pathology results are available or if further investigation (eg radiography) is required.
Note: NDIS = National Disability Insurance Scheme

Figure 1. Commonly missed causes of challenging behaviour in people with developmental disability

abuse and trauma

constipation

dental pain and gum disease

gastro-oesophageal reflux disease (GORD) and Helicobacter pylori infection

hunger and poor nutrition

infection—consider immunisation status

medication adverse effects (see Medication reviews)

poor physical activity

psychiatric disorder (eg anxiety, depression)

sensory deterioration or loss (eg vision, hearing)

sleep problems

social or environmental changes, including irregular contact, or loss of contact with a trusted carer or friend (eg change of staff or co-residents, death of a family member)

thyroid disease

unrecognised or poorly controlled neurological condition (eg epilepsy)

unrecognised physical injury (eg fracture)

Table 2. Questions to guide taking a history of challenging behaviour in a person with developmental disability
General questions about the behaviour	Examples of further prompting questions
When and under what conditions is the behaviour most likely to occur? When and under what conditions is the behaviour least likely to occur?	When did it begin? What is the relationship to mealtimes? Is it worse at night? Has it changed, and if so, when did it change?
What happens immediately before the behaviour? What happens immediately after the behaviour? What typically brings about resolution?	Where is the person? What are they doing? What are others doing? What don’t they have available to them? What do they get when it occurs (eg to stop the behaviour)?
Does any activity or event make the behaviour more or less likely?	Is it more likely with exercise? Does it follow eating certain foods?
What is the long-term history of the behaviour?	Does it follow certain medical events? Has it occurred in association with a particular medical problem? Has it occurred in association with a drug being withdrawn or started? Has it always been present, but less severely than now? Has it been different when different people were around or in different situations?
Is there a medical cause for the behaviour (eg physical or psychiatric condition)?	What is the underlying cause of the person’s developmental disability? What is their medical history? Does the person have any associated medical disorders (or a known genetic condition) that could (partly) explain their behaviour?