Management of a Person Displaying Acute Behavioural Disturbance
Published: 03 October 2021
Every person, including healthcare workers, deserves to feel safe in healthcare settings - but what happens if you’re caring for a person experiencing acute behavioural disturbance (ABD) who is displaying agitation or aggression? (SCV 2021; ANZCOR 2020)
What is Acute Behavioural Disturbance?
Acute behavioural disturbance (ABD) is behaviour that has the potential to cause serious harm, major injury or death to the affected person, yourself or others. It includes behaviours such as making threats, aggression, extreme distress and self-harm (ANZCOR 2020).
When encountering ABD, ensuring the safety of all people present is your immediate priority (ANZCOR 2020).
In some cases, the person displaying abnormal behaviour may not be a client but instead, other people present such as family members or friends. There may even be situations where several people are displaying behavioural disturbance at once (ANZCOR 2020).
Causes of Acute Behavioural Disturbance
The causes of ABD vary, with some being potentially life-threatening. Determining why this behaviour is occurring is crucial in managing and treating the person (ANZCOR 2020).
Increased arousal, demonstrated by behaviours such as restlessness, pacing, crying, wringing hands, screaming or yelling
Appearing agitated, excited, scared or frantic
Rigid body language, which suggests that the person is making a significant effort to control themselves
Abnormal thinking, perceptions or ideas
Wearing inappropriate clothing for climate or context
Altered state of consciousness
Acting aggressive, violent or argumentative.
Red flag indicators requiring escalation include:
High body temperature, excessive sweating or being hot to touch
Insensitivity to pain
Rapid respiratory rate and rapid pulse rate
Extreme arousal with aggression or violence
The first episode of ABD in a person aged 45 or over
Abnormal vital signs
Focal neurologic findings
Decreased awareness and attention
Known substance withdrawal or intoxication
No clear trigger for the behaviour (in autistic people or those with intellectual disability)
Known exposure to toxins.
(ANZCOR 2020; SCV 2021)
There are two tools that can assist in the identification of ABD: the sedation assessment tool (SAT) and the STAMP framework of behaviours that may indicate increasing distress (SCV 2021).
Sedation Assessment Tool (SAT)
The SAT is used to measure distress and sedation levels by taking into account both responsiveness and speech. A score for each category is determined, and the person’s overall SAT score will be whichever of the two scores is higher (QAS 2017).
For example, a person who is highly anxious and agitated (+2) but talkative (+1) will have a SAT score of +2 (QAS 2017).
Combative, violent, out of control
Continual loud outbursts
Highly anxious and agitated
Anxious or restless
Awake and calm or cooperative
Asleep but rouses if their name is called
Slurring or prominent slowing
Responds to physical stimulation
Few recognisable words
No response to stimulation
(Adapted from SCV 2021)
The STAMP framework describes behaviours that may indicate increasing distress and the potential for behavioural escalation:
Lack of eye contact (depending on the person’s culture and disability)
Tone and volume of voice
Increased voice volume
Expressed lack of understanding about care processes
Talking under their breath
Criticising care just loudly enough to be heard
Repeating the same or similar phrases
Walking around confined areas
Walking back and forth to the staff station
Flailing around in bed
(Adapted from SCV 2021)
Management of Acute Behavioural Disturbance
Remember that your immediate priority should be the safety of all people present.
Ensure safety and seek appropriate help or support (e.g. ambulance, security services, police)
Reassure the person and practise active listening without judgement (if safe to do so)
Seek further advice or assessment if required
Perform appropriate management if the person deteriorates or loses consciousness
Provide Basic Life Support if the person becomes unresponsive and is not breathing normally.
De-escalation is the use of strategies, techniques and methods to reduce agitation. This may involve communication (both verbal and non-verbal), environmental modification and working collaboratively with the person towards solutions. De-escalation works best when commenced early (SCV 2021).
When attempting to de-escalate, always treat the person with respect and empathy and consider factors such as gender identity, cultural identity, language, trauma history, medical conditions and individual needs (SCV 2021).
If not performed properly, de-escalation strategies may exacerbate the situation. Ensure those who are attempting to de-escalate are appropriately trained in these techniques (ANZCOR 2020).
Avoid being alone with the person, but move unnecessary bystanders and staff out of sight
If possible, stay at least two arm lengths away from the person
Be vigilant for signs of violence or escalation
If possible, ensure there is access to at least two exits
Remove objects that could be used as weapons
If the person is in conflict with another individual, try to keep them separate
Speak politely and allow time for communication without rushing
Centre the conversation on the person’s needs
Use a concerned and interested tone of voice
Ask open questions
Avoid shouting raising your voice, make threats, giving orders or advice, or arguing
Consider alternative forms of communication such as communication boards, symbols or signs
Use non-threatening body language; avoid placing your hands on your hips or in your pockets, finger wiggling, prodding, crossing your arms or clenching your fists
Move slowly and gently
If possible, reduce stimuli such as noise, smells, lights and movements
Keep the person’s cultural background in mind
If possible, seek assistance from someone who the person knows and trusts without leaving the scene
Ensure the person’s privacy
Ensure the person can access food, drink, the toilet, bedding etc.
(ANZCOR 2020; SCV 2021)
If you ever feel threatened or unsafe in any way, remove yourself from the situation and seek appropriate support and assistance (ANZCOR 2020).
Verbal de-escalation (conversation) is the safest method of de-escalation. There are three stages of verbal de-escalation:
1. Get started
Assess whether you need extra support of back-up
Ensure a colleague knows where you are going
Create a safe and helpful communication space
Introduce yourself to the person
Explain that you want to help the person and that you want to work together to ensure they feel safe.
2. Listen and Determine the Problem
Use the person’s name
Ask open-ended questions in order to find out what is happening
Use simple words and short sentences
Repeat, paraphrase and check your understanding
Answer the person’s questions
Clarify any misunderstandings.
3. Find Solutions
Work together and compromise
Offer realistic options
Explain the reasons for rules and decisions
Ask the person whether there is anything you can do to help them work through the issue
Ask the person whether there is anything you can do to help them feel safe.
In some cases, you may need to use a restrictive practice as a last resort to prevent immediate harm to the person, yourself or others. This must only be performed after all other less-restrictive options have been attempted or considered (SCV 2021).
Restrictive practices are subject to legal requirements and obligations. Always adhere to these requirements and refer to your organisation’s policies and procedures.