3.2 Non-Pharmacological Management of Agitation and Disruptive Behaviour

3.2.1 Assessment of Agitation and Aggressive Behaviour

What test is available to assess for agitated and aggressive behavior?  What are its strengths and weaknesses?

Agitated Behavior Scale, designed to assess agitation in patients by those working with them.  14 item scale, with each item scoring 1-4 (total range 14-56)


The length of the scale (14 questions), amount of time to complete it (<30 minutes) and its availability makes the scale very practical.


Risk of over diagnosis of agitation 1


Click here to view the Agitated Behavior Scale: http://www.tbims.org/combi/abs.absrat.html


  • The ABS was designed to assess agitation in patients by those working with them.
  • The scale, which began as a 39 item scale, was reduced to 14 items, with each item     scoring 1 to 4, (from absent to present to an extreme degree).
  • The scale which was originally tested by nurses, occupational therapists (OT), physiotherapists (PT) and other hospital staff, was designed to be used by allied health professionals 2
  • According to Levi et al. 3despite the availability of the scale, agitation remains unmeasured by most who work with the TBI population.

What are some of the practical advantages of using an objective scale for assessing agitation?
  1. Assess pattern of agitation;
  2.  Assess the level of agitation, which then can dictate treatment;
  3. Assess the response of agitation to interventions;
  4. Numbers mean something; ABS >21 = agitation, <23 unlikely to be violent, >28 = treatment with pharmacological agents.

3.2.2  Treatment of Agitation and Agression Post-TBI

Case Study (continued)

The patient does not want to take medications but is still exhibiting aggressive and agitated behaviour.  Non-Pharmacological Methods

What non-pharmacological methods of managing agitation and aggressive behavior are available in a case such as this?
  • Do not leave alone
  • Keep noise and traffic in room to a minimum
  • Familiarize with basic information
  • Physical reassurance through talking or touching patient
  • Accommodation in a highly-structured setting
  • Establish desired behaviour
  • Remove patient from group or change activity if agitation increases
  • Freedom of movement to control outbursts
  • Stimulating simple self-care tasks and participation
  • Assess for treatable pathology
  • Assess for sleep/wake cycle

Which non-pharmacological options are available to treat his agitation and disruptive behavior which have been studied in research studies?
  1.  Feedback
  2. Cognitive training
  3. Music therapy
  • Emotional problems in 70% of patients improved after an intensive, holistic and multidisciplinary program 4.

What evidence is there for antecedent management and/or feedback?

  1. There is Level 4 evidencethat antecedent managementand/or feedback of consequences can reduce aggression and/or agitation.
  • Due to the individual’s needs and physical or emotional disabilities following an ABI, it is extremely difficult to assess behavioural management programs over all as they are designed for a specific person with a specific issue or issues.
  •  ERABIincluded studies that looked at the benefits of token economies, positive reinforcements, anger management, and social skills training 5.
  •  Each of these techniques alone or in combination has been used to help reduce the level of agitation or aggression someone with an ABI may be experiencing.
  • Although the sample sizes in each study was small there is some evidence tosuggest that a behavioural approach is successful in reducing undesirable behaviour 5.

For a more detailed discussion on the studies included in ERABI please see ERABI/Mental Health Issues Post ABI.

What evidence is there for multi-intervention training programs?
  1. There is Level 2 evidence that Natural Setting Behavior Management may help to change behavior.
  2. There is Level 2 evidence to suggest that participating in Coping Skills Group (CSG) assisted in improving adaptive coping in the long term.
  3. There is Level 2 evidence based on one RCT that anger management reduces aggressive behavior.
  4. There is Level 4 evidence that social skills training reduce aggressive behaviour.

Multi-interventional Training Programs include:

  • Social Skills Treatment
  • Natural Setting Behavior Management
  • Participating in a Coping Skills Group
  •  Anger Management
  • Structuring an individual’s environment initially with high support, and then reducing it, and involving the clients in a collaborative manner, aggressive behaviour was significantly reduced 6.
  • The impact of systematic databased feedbackwas evaluated on 3 TBI patients with maladaptive behaviour (pseudoseizures, non-compliance with rules, verbal aggression and sexually inappropriate behavior).  Variability and frequency of maladaptive behaviour generally decreased from baseline (2 to 5.1 per week) to completion (0.18 to 1.8 per week) 7.
  • Positive reinforcement significantly and dramaticallywas found to reduce aggressive behaviorin patients with closed head injuries 8.
  • ABI patients whose disturbed behaviours prevented rehabilitation in ordinary settings were placed in a specialized TBI unit that used a wide range of physical, cognitive behavioural, occupational and social techniques based on positive reinforcement and a token economy. 
  • Post treatment 2/3 of patients had improved placements after treatment; only one person had a substantial improvement. Quality of life had improved as measured by improved relationships with caregivers and an improvement in living arrangements9.

Social Skills Treatment

  • McDonald et al.10 found individuals who had been randomly assigned to a social skills training group (where they received both group and individual sessions) social behavior improved; however, when looking at the treatment effects results indicate no interaction effects for the social group relative to the control or waitlist groups.
  • Those in the skills training group made significant improvement on the Partner Directed Behaviour Scale (PDBS) compared to the placebo group and the waitlist group. Changes were not noted for any group when looking at social functioning and social participation post treatment. 
  • Treatment effects were found to be modest at best and limited to direct measures of social behaviour.
  • In an earlier study individuals participated in asocial skills training program lasting approximately 28 weeks.
  • Behaviours receiving the lowest ratings were targeted for intervention.
  • The program was shown to be successful in remediating a variety of social deficits found in the study participants.
  • The interventions were particularly effective when addressing motoric target behaviours rather than complex verbal behaviours11

Natural Setting Behavior Management

  •  In a RCT conduced by, Carnevale and colleagues 12, individuals were randomly placed in one of three groups (the control group (no treatment was given), the education group and the Natural Setting Behaviour Management group (who received both education and participated in an individual behavior modification program).
  • Changes in behavior were not seen at the first two follow-up time periods; however, differences were found between the control and the experimental groups in theemotion exhaustion scale. 
  • Treatment did not affect the scores on the neurobehavioural functioning inventory.

Coping Skills Intervention

  • Although not stable over time, both groups increase their adaptive coping skills following their participation in the coping skills group (CSG).
  •  However, no significant changes in their anxiety or self-esteem scores following the CSG.
  •  Results also showed that levels of depression and psychosocial dysfuntion improved for both groups, suggesting participation in the CSG did not affect their scores 13.

Anger Management

  • In one cohort study,O'Leary 14had participatns attend weekly sessions for 10 weeks.  Sessions addressed coping skills and managing daily stress.
  • Results showed that aggression decreased following these weekly session and these effects were maintained for another 10 weeks.
  •  Medd & Tate 15 evaluated the effectiveness of an anger management therapy program in 16 ABI patients.
  • Results indicated a decrease in anger (as measured by the State-Trait Anger Expression Inventory) immediately and two months following treatment.


For a more detailed discussion of these studies please see ERABI/Mental Health Issues Post ABI.

What is the evidence for music therapy for agitation?
  1. There is Level 2 evidence based on one non-RCT that music therapy reduces agitation.
  2. There is Level 4 evidence that music therapy reduces psychomotor agitation.
  3. There is Level 4 evidence to suggest that music therapy improves the mood of ABI adults.
  • Music therapy is an approach that “consists of using music therapeutically to address physical, psychological, cognitive and/or social functioning for patients of all ages” 16
  • Music therapy has been used with a variety of patients and was formally recognized as a therapeutic tool in 1950. More recently, music therapy has been used with TBI patients to decrease agitation.
  •  Formisano et al. 17found that music therapy had a beneficial effect in reducing post-coma agitation. 
  • Baker 18showed that agitation decreased significantly after exposure to the live and taped music.

Two non-pharmacological methods of managing agitation and aggressive behavior which have been studied in the literature include the 1) Stimulus control learning procedure and 2) Response consequence learning?  Describe these two approaches.

Stimulus control learning procedure

  1. Attempts to change behavior by manipulating antecedent events – relies on the patient’s ability to discriminate those aspects of the environment that act as cues for an undesirable behavior.

Response consequence learning

  1. Focuses on the association between the behavior and its subsequent consequences, i.e. time out.

Although unproven, it is logical to assume that the most effective intervention for posttraumatic agitation would combine both pharmacologic and nonpharmacologic strategies.

Behavioral Intervention

The two techniques that have been shown to be effective are:

1.    The stimulus-controllearning procedure 19:

  • Here behavior is changed by attempting to change the events that lead to these behaviours.
  • Individuals are asked to identify environmental cues that trigger the behaviours that have been identified as undesirable.
  • When faced with these “cues” or signals, individuals are asked to select a more acceptable and appropriate response.

 2.    Response-consequence learning 19 

  •  Here the focus is on the behavior and the consequence that results from this behavior.
  • Examples include: time-out and token economies,

Emergence from Coma

  • Individual who are emerging from coma these techniques have not yet been proven to be effective as this type of learning may be impaired.
  • For these individuals an environment that is structured, consistent, reduces the amount of excessive sensory stimulation the patient is exposed to and provides a selection of productive activities is a more commonly used behavioural intervention19.