Challenging behaviour and PBS — functional analysis to limited medication (MEQ)

(i) Definition. Challenging behaviour is culturally abnormal behaviour of such intensity, frequency or duration that physical safety of the person or others is seriously jeopardised, or that seriously limits ordinary community access. It is a description of impact, not a DSM/ICD diagnosis. Psychiatric disorders may cause or coexist with CB but must be diagnosed on their own criteria; CB alone is not “psychosis.”^[1]

(ii) Functional assessment. Collect multi-informant history and ABC charts across settings. Hypothesise maintaining functions: attention, escape/avoidance of demand (highly plausible here during showering), tangible access, or automatic/sensory. Examine medical pain (dental, constipation), sensory aversion to water/temperature, and communication barriers. Experimental functional analysis principles (Iwata-type conditions) refine hypotheses when safe and specialist-supported.^[3]

(iii) PBS plan. Person-centred quality-of-life goals; function-linked proactive strategies (environmental redesign of personal care, predictable routine, functional communication training for “stop/help”, graded exposure or adapted washing methods); active support and staff consistency; least-restrictive reactive strategies pre-planned; data review; multiagency ownership; explicit reduction of restrictive practices and chemical restraint.^[1]

(iv) Guidelines and Tyrer. NICE NG11 prioritises psychosocial and environmental interventions informed by assessment; medication only when behaviour poses serious risk and non-drug approaches are insufficient or while programmes are established, with regular review. Tyrer 2008: risperidone and haloperidol were not superior to placebo for aggressive CB in adults with ID — not routine first-line treatment.^[1][2]

(v) Current risperidone. Do not escalate by default. Reassess indication (no psychosis documented). Optimise PBS and medical care first. Prefer supervised reduction/discontinuation plan with enhanced support if risk allows, consistent with deprescribing evidence and overmedication epidemiology. If residual severe injury risk persists despite intensive PBS, any medicine trial needs named target, capacity/consent process, lowest effective dose, time limit, and monitoring (weight, metabolic panel, EPS, prolactin symptoms, sedation) with a stop date — not open-ended dose increases for staff convenience.^[2][4][5][6]