Last week, Dr Alberto Bonilla Miralles — Clinical & Occupational Psychologist and Director at Clement Mind — was invited to present at a UKABIF (UK Acquired Brain Injury Forum) event, sharing expertise on one of the most complex areas in neuropsychological rehabilitation: the management and resolution of challenging behaviours following an acquired brain injury (ABI).
What counts as a 'challenging behaviour'?
The presentation opened by reframing the concept: challenging behaviours are not simply acts of aggression or non-compliance — they are any responses (or absence of responses) that threaten the recovery pathway of a service user, including risks to their own safety or that of those around them. Crucially, they exist on a continuum of frequency and intensity, and understanding where a person sits on that continuum is central to any effective intervention.
Behaviours were categorised as excess (overt) — such as physical aggression, verbal outbursts, or inappropriate social conduct — and deficit (covert) — including withdrawal, absconding, lack of initiation, or repetitive behaviours. Both types can be equally disruptive to recovery.
Understanding the 'why': ABC Functional Assessment
A key theme of the talk was the importance of not managing behaviour in isolation. Using an ABC (Antecedent–Behaviour–Consequence) functional assessment model, Dr Bonilla Miralles illustrated how behaviours almost always serve a function — from expressing emotional distress to compensating for impaired executive functioning. Secondary gains were also explored as a crucial but often overlooked driver.
A structured decision-making process
The presentation outlined a five-stage process model for providing behaviour support:
- Consideration of ethical and legal issues (including the risk of iatrogenesis)
- Assessment — using tools such as the OAS-MNR/SASBA, direct observation, and inventories
- Formulation — understanding the individual's history, cognitive profile, and the function of their behaviours
- Intervention
- Evaluation
A detailed anonymised case formulation was shared, showing how factors such as fatigue, hypersensitivity, impulsivity, reduced insight, and impaired executive functioning interact to produce challenging presentations in a real clinical context.
Intervention techniques
The session covered a wide range of evidence-based contingency management strategies, grounded in behavioural principles. These included differential reinforcement, extinction, fading, response-cost, and self-monitoring training for decreasing behaviours; and positive reinforcement, shaping, chaining, token economy, and errorless learning for increasing adaptive behaviours.
Stimulus control techniques and backward chaining were also discussed in depth — particularly their value in severe cases where therapeutic scaffolding is needed to build functional independence step by step.
Further reading
For those interested in learning more about how neuropsychology can support the understanding and management of challenging behaviours after brain injury, visit: clementmind.com/neuropsychology/challenging-behaviours
