Behaviour that challenges is behaviour — such as aggression, self-injury, shouting, repeated actions, withdrawal or damaging property — that is difficult for services, families or carers to manage and may put the person or others at risk. It is not a diagnosis, and it is not a description of the person. NICE says it “may serve a purpose” for the person, such as communicating, avoiding demands or getting sensory stimulation, and that it “often indicates an unmet need” — pain, fear, boredom or a care environment that is not working. That is why good practice starts with finding the cause, not controlling the behaviour. Restraint is not banned in care, but it is lawful only when necessary and proportionate.
At a glance: Nexis CPD’s £9 Managing Behaviour that Challenges course covers why behaviour happens, the ABC model, proactive person-centred strategies, de-escalation and safe, proportionate responses. It is CPD accredited and 100% online with a verifiable e-certificate, and any three courses cost £18. It is awareness training: it does not teach physical intervention or restraint techniques, and it is not a regulated qualification.
What does “behaviour that challenges” mean?
The phrase comes from the learning disability field and is now used widely across health and social care, including dementia and mental health services. The NICE guideline NG11, Challenging behaviour and learning disabilities (published 29 May 2015), explains the term in its context section:
“‘Behaviour that challenges’ is not a diagnosis and is used in this guideline to indicate that although such behaviour is a challenge to services, family members or carers, it may serve a purpose for the person with a learning disability (for example, by producing sensory stimulation, attracting attention, avoiding demands and communicating with other people).”
NICE lists aggression, self-injury, stereotypic behaviour (repeated movements such as rocking or hand flapping), withdrawal, and disruptive or destructive behaviour. It adds that the same behaviour “may be considered challenging in some settings or cultures but not in others”, and that it “often results from the interaction between personal and environmental factors”.
NHS England’s STOMP programme goes further, describing behaviour thought to be challenging as “not a diagnosis, more a social construct that may identify a person’s communication needs and the impact of environmental triggers”. You will still see the older phrase “challenging behaviour” — it is in the title of NICE’s own guideline — but the guideline text uses “behaviour that challenges” to keep the focus on the behaviour and its impact rather than on the person. Whatever the label, the practical point is the same: the behaviour is a signal, and the job of care staff is to work out what it is saying.
Why do people behave in ways that challenge?
NICE’s guideline says staff should understand “that behaviour that challenges often indicates an unmet need”, and that the way staff and carers respond to behaviour can itself keep it going. Common reasons include:
- Communication. A person who cannot say “I’m in pain”, “I’m frightened” or “I don’t want to” may show it instead. NICE lists communication difficulties — both expressing and understanding — as a risk factor.
- Physical health. NICE’s recommendations on annual health checks include reviewing how behaviour “may be linked to any physical health problems” and managing pain. The NHS page on coping with dementia behaviour changes says that if a change “comes on suddenly, the cause may be a health problem. The person may be in pain or discomfort from constipation or an infection.”
- Getting or avoiding something. NICE gives getting help, attracting attention and avoiding demands as common purposes.
- Sensory needs. Behaviour may produce stimulation the person wants, or help them escape stimulation they cannot cope with.
- The care environment. NICE names environments with “limited opportunities for social interaction and meaningful occupation, lack of choice and sensory input or excessive noise”, and those that are “crowded, unresponsive or unpredictable”. It also lists environments “characterised by neglect and abuse, and those where physical health needs and pain go unrecognised or are not managed”.
- Change. Significant staff changes or moving to a new care setting are named risk factors.
NICE also warns care staff to be alert to abuse. Its guideline says to “be aware of or suspect abuse as a contributory factor to or cause of behaviour that challenges” in children with a learning disability, and notes that adults with a learning disability “are vulnerable to maltreatment and exploitation”. A sudden change in behaviour can be a safeguarding signal — see our guide to safeguarding adults.
Who is more likely to show behaviour that challenges?
According to NICE, behaviour that challenges is “relatively common” in people with a learning disability, and more common in people with more severe disability. It gives prevalence rates of “around 5–15% in educational, health or social care services for people with a learning disability”, higher in teenagers and people in their early twenties, and “30–40% in hospital settings”.
NICE recommendation 1.4.1 asks everyone involved in care — including family members — to record factors that may increase the risk. Personal factors include:
- a severe learning disability;
- autism;
- dementia;
- communication difficulties;
- visual impairment, which may lead to increased self-injury and repetitive behaviour;
- physical health problems;
- age, with rates peaking in the teens and twenties.
Environmental factors include abusive or restrictive environments, too little or too much sensory stimulation, low engagement with staff, disrespectful relationships and poor communication, and changes such as a move or new staff. Behaviour that challenges “often develops gradually”, NICE says, which is why noticing and recording early changes matters. Our guides to autism awareness and dementia explain how each condition can affect communication and behaviour.
What does behaviour that challenges look like in dementia?
In dementia care, the same idea is often described as “distress” or “behaviours indicating distress”. The NHS says that in the middle to later stages of most types of dementia a person may start to behave differently, and lists common changes:
- repeating the same question or activity over and over;
- restlessness, such as pacing, wandering and fidgeting;
- night-time waking and sleep disturbance;
- following a partner or carer around everywhere;
- loss of self-confidence, which may look like apathy.
The NHS reminds carers that “these behaviours may be how someone is communicating their feelings”, and that sometimes they are not a dementia symptom at all but frustration at not being understood, or at surroundings that now feel confusing. It suggests looking for triggers — time of day, noise and clutter, being asked to do something the person does not want to do — and says keeping a diary “for 1 to 2 weeks can help identify these triggers”.
NICE’s dementia guideline, NG97, sets the order of priorities. Before starting any treatment for distress, staff should carry out a structured assessment to “explore possible reasons for their distress” and “check for and address clinical or environmental causes (for example pain, delirium or inappropriate care)” (recommendation 1.7.1). Psychosocial and environmental interventions come first, as “initial and ongoing management” (1.7.2).
The NHS also suggests a daily routine with walks, something to occupy restless hands, and reassurance that the person is safe when they ask to “go home”. Our guide to person-centred care explains why knowing someone’s history makes this possible.
How do you find out what is causing the behaviour?
NICE recommends a phased approach “aiming to gain a functional understanding of why the behaviour occurs”. Put simply, the question is not “how do we stop this?” but “what does this behaviour get or avoid for the person?”. A functional assessment (recommendation 1.5.9) should include:
- a clear description of the behaviour, including behaviours that tend to happen together;
- the events, times and situations that predict when the behaviour will — and will not — happen across the person’s daily routine;
- the consequences that keep the behaviour going, which is its function or purpose;
- summary statements or hypotheses linking triggers, behaviour and what reinforces it;
- direct observations to test those hypotheses.
Front-line staff usually contribute through structured recording. Many services use ABC charts: Antecedent (what happened just before), Behaviour (exactly what the person did, described objectively) and Consequence (what happened straight after, including how staff responded). “Hit a carer with an open hand during personal care after being told it was time for a bath” is useful; “was aggressive again” is not.
NICE also wants a baseline of how often and how intensely the behaviour happens, and of the person’s quality of life. It stresses that the aim “should always be to improve the person’s overall quality of life” — not simply to reduce incidents.
What is a behaviour support plan?
After assessment, NICE recommends a written statement, or formulation, of what has led to the behaviour and what function it serves, and then a written behaviour support plan (recommendation 1.6.1). The plan should:
- set out proactive strategies to improve quality of life and remove the conditions that promote the behaviour — for example “reducing noise, increasing predictability” and structured, personalised daily activities;
- help the person develop an alternative behaviour that achieves the same purpose, such as a new way to communicate or to calm themselves;
- list preventive strategies for the early signs of distress, including relaxation techniques and “distraction and diversion onto activities they find enjoyable and rewarding”;
- set out reactive strategies for behaviour that cannot be prevented, including how staff should respond if agitation escalates and there is significant risk of harm;
- include risk management, and be realistic about what staff and families can deliver;
- be monitored with objective data and reviewed “fortnightly for the first 2 months and monthly thereafter”, or sooner if behaviour or restrictive interventions increase or quality of life falls.
This proactive approach is often called positive behaviour support (PBS). The Department of Health and Social Care’s guidance Positive and Proactive Care: reducing the need for restrictive interventions (3 April 2014, England) says that individualised support plans, “incorporating behaviour support plans, must be implemented for all people who use services who are known to be at risk of being exposed to restrictive interventions”.
NICE’s guideline also states that the focus should be “on improving the person’s support and increasing their skills rather than changing the person”, and that people and their families should be involved in planning. For a care worker, the plan is only useful if you have read it and follow it consistently — including on night shifts and when agency staff are on duty.
What should you do when someone becomes distressed or agitated?
The person’s own plan comes first, because what calms one person may make another worse. General principles drawn from NICE and NHS guidance include:
- Look for the early signs the plan describes and act then, using the agreed calming, distraction or diversion strategies.
- Check the basics — pain, hunger, thirst, the toilet, temperature, noise, tiredness — especially when the behaviour is new or sudden.
- Stay calm and reassuring. The NHS advises being “tactful and patient” and offering reassurance, and reminds carers that the person “is not being deliberately difficult”.
- Reduce demands. If a task is the trigger, it can often wait, be offered differently, or be done by someone else.
- Give space and keep others safe if there is a risk of harm, while keeping the person in view.
- Use the least restrictive response. NICE says reactive strategies should be “a last resort”, used alongside proactive work, with “a graded approach that considers the least restrictive alternatives first”.
Afterwards, record what happened factually, tell the person in charge, and take part in any debrief. HSE’s guidance on violence at work also applies to care staff who are hurt or threatened — see our guide to violence at work for employers’ duties and when an injury must be reported.
Is restraint allowed in care?
Yes, but only within tight legal limits. Many people are surprised by how widely “restraint” is defined. Under regulation 13(7) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, a person controls or restrains a service user if they:
- “uses, or threatens to use, force to secure the doing of an act which the service user resists”, or
- “restricts the service user’s liberty of movement, whether or not the service user resists”,
“including by use of physical, mechanical or chemical means”. So holding someone’s arms, locking a door, using a lap belt or bed rails to stop someone getting up, or giving medication to sedate someone can all be restraint.
Regulation 13(4)(b) says care must not include “acts intended to control or restrain a service user that are not necessary to prevent, or not a proportionate response to, a risk of harm”. CQC’s Regulation 13 guidance says providers must have “a zero tolerance approach to abuse, unlawful discrimination and restraint”, and that if restraint is used it must be “only used when absolutely necessary”, proportionate, based on an assessment of the person’s needs and mental capacity, and in line with legislation and guidance. CQC says it can prosecute for breaches of regulation 13(1) to 13(4) that result in avoidable harm or significant risk of harm.
For people who lack capacity, section 6 of the Mental Capacity Act 2005 sets two conditions before restraint is protected from liability: the person restraining must reasonably believe it is “necessary to do the act in order to prevent harm” to the person, and the act must be “a proportionate response” to the likelihood and seriousness of that harm. Restrictions that add up to a deprivation of liberty need separate legal authorisation — see our guides to the Mental Capacity Act and DoLS.
Positive and Proactive Care sets out clear red lines for health and adult social care in England, including:
- “Staff must not deliberately restrain people in a way that impacts on their airway, breathing or circulation, such as face down restraint on any surface, not just on the floor.”
- “If restrictive intervention is used it must not include the deliberate application of pain.”
- Any restrictive intervention “must always represent the least restrictive option to meet the immediate need.”
- “Staff must not use seclusion other than for people detained under the Mental Health Act 1983.”
NICE adds that any restrictive intervention should be documented, reviewed and discussed with everyone involved, and accompanied by a plan to reduce the need for it in future. Physical intervention should only ever be used by staff trained, in person, in the specific techniques your service has approved.
Can medication be used to manage behaviour that challenges?
Sometimes, but not as a first resort, and never on its own. For people with a learning disability, NICE recommendation 1.8.2 says antipsychotic medication should be considered only if psychological or other interventions have not produced change within an agreed time, treatment for any underlying health problem has not reduced the behaviour, or “the risk to the person or others is very severe”. It should “only” be offered alongside psychological or other interventions, and initially prescribed and monitored by a specialist.
For people living with dementia, NICE NG97 says to “only offer antipsychotics” to people who are at risk of harming themselves or others, or experiencing agitation, hallucinations or delusions causing them severe distress. They should be used at the lowest effective dose for the shortest time, with reassessment “at least every 6 weeks”.
NHS England’s STOMP programme exists because of over-use. It says that in 2025 people with a learning disability were thought to be 15 times more likely, and autistic people 7 times more likely, to be prescribed an antipsychotic than the general population. For care staff, the practical points are to record how the person is before and after any “as required” (PRN) dose, report side effects such as sedation, and raise it if medication seems to be used for staff convenience. Medication given to control behaviour rather than to treat a condition can be chemical restraint under regulation 13.
What training do care workers need for behaviour that challenges?
No law sets a named course or a fixed refresher interval, but the expectation is clear. CQC’s regulation 13 guidance says that as part of induction, staff “must receive training that is relevant to their role and at a suitable level” so that restraint and restrictive practices are only used when absolutely necessary, in line with current national guidance and as a last resort, and that providers should keep staff up to date “at appropriate intervals”.
NICE recommendation 1.1.6 says all staff working with people with a learning disability and behaviour that challenges should be trained to deliver proactive strategies: personalised daily activities, adapting the environment and routine, teaching alternative skills, involving people and families, calming and diverting early distress, and reactive strategies. NICE also recommends regular high-quality supervision and personal and emotional support for staff.
For dementia services, NICE NG97 recommends that care providers give staff “additional face-to-face training and mentoring”, including on responding to agitation, aggression, pain and distress, reducing the need for antipsychotics, and “promoting freedom of movement and minimising the use of restraint”. Online courses are a good way to cover the knowledge — why behaviour happens, the law and the principles — but they sit alongside, not instead of, in-person training and supervision in your service.
Which courses help with behaviour that challenges?
These three £9 courses work well together for care workers, senior carers and team leaders, each with a verifiable certificate:
- Managing Behaviour that Challenges — why behaviour happens, the ABC model, proactive person-centred strategies, de-escalation and safe, proportionate responses.
- Dementia Awareness — how dementia affects the person, and compassionate, person-centred care that protects dignity and rights.
- Mental Capacity Act — capacity, best interests and the limits on restraint.
Autism Awareness and Conflict Resolution and De-escalation are useful alternatives depending on who you support. Any three courses cost £18 with the pay-for-2-get-3 offer — add them to the cart and the discount applies automatically. These are awareness courses. They are not regulated qualifications, and they do not teach physical intervention, which must be taught in person by an approved trainer where your service uses it.
Frequently asked questions
What is meant by behaviour that challenges?
It is behaviour such as aggression, self-injury, repetitive behaviour, withdrawal or destructive behaviour that is a challenge to services, families or carers and may put the person or others at risk. NICE says it is not a diagnosis and may serve a purpose for the person, such as communicating or avoiding demands.
What are the main causes of behaviour that challenges?
Common causes include pain or illness, difficulty communicating, fear or confusion, boredom or a lack of meaningful activity, too much or too little sensory stimulation, being asked to do something the person does not want to do, and changes in staff or surroundings. NICE says it often indicates an unmet need.
What is the ABC approach in care?
ABC stands for antecedent, behaviour and consequence. Staff record what happened just before the behaviour, exactly what the person did, and what happened straight afterwards. Over time the records help identify triggers and the purpose the behaviour serves, which informs the person’s behaviour support plan.
Is it legal to restrain someone in a care home?
Only when it is necessary to prevent harm and a proportionate response to the risk. Restraint includes physical holds, restricting movement such as locking doors, and medication used to control behaviour. CQC regulation 13 prohibits unnecessary or disproportionate restraint, and deliberate face-down restraint and the use of pain are ruled out by government guidance in England.
How often should a behaviour support plan be reviewed?
NICE recommends reviewing it fortnightly for the first 2 months and monthly after that, and sooner if the behaviour or the use of restrictive interventions increases or the person’s quality of life gets worse.
Can antipsychotics be used for behaviour that challenges?
Only in limited circumstances, such as when other interventions have not worked or the risk of harm is very severe, and always alongside non-drug approaches. For people with dementia, NICE says antipsychotics should be reviewed at least every 6 weeks and used at the lowest effective dose for the shortest time.
Understand the behaviour, support the person
£9 per course. CPD accredited, 100% online, verifiable e-certificate. Pay for 2, get 3 — any 3 courses for £18.
This article is general information, not legal or clinical advice. It summarises NICE guidelines NG11 and NG97, NHS and NHS England guidance, CQC’s Regulation 13 guidance, the Mental Capacity Act 2005 and DHSC’s Positive and Proactive Care guidance at the time of writing; CQC regulation and Positive and Proactive Care apply in England, and Wales, Scotland and Northern Ireland have their own regulators and guidance. Always follow the individual’s care and behaviour support plan and your employer’s policies. If someone is in immediate danger, call 999. A Nexis CPD awareness course is CPD accredited but is not a regulated qualification and does not provide physical intervention training.