Behaviour Support Plans After Brain Injury: Why Occupation, Function and Environment Matter
by Nikki Thompson & Gillian Munday
Behavioural changes following brain injury can significantly affect a client’s ability to participate in everyday life. Presentations such as verbal aggression, impulsivity, emotional dysregulation, reduced frustration tolerance, social disinhibition or resistance to support can impact relationships, community participation, employment, education and independence.
When behaviours of concern emerge, intervention often focuses on the behaviour itself. However, from an occupational therapy perspective, behaviour should not be viewed in isolation. Instead, it should be understood within the context of the client’s occupations, routines, environment and functional abilities.
This perspective is particularly valuable when developing Behaviour Support Plans (BSPs) following brain injury. Challenging behaviours are recognised as one of the most disabling long-term consequences of acquired brain injury, often affecting participation, relationships, community integration and overall quality of life (Hicks et al., 2021).
Behaviour Support Plans
A Behaviour Support Plan (BSP) is a structured, person-centred document that identifies behaviours of concern, explores the factors contributing to those behaviours, and outlines proactive strategies to support positive outcomes. Following brain injury, a BSP aims to help everyone involved in the individual’s care and rehabilitation understand potential triggers, recognise early warning signs and respond consistently, with the goal of reducing distress, promoting participation and improving quality of life.
Whilst BSPs are often associated with behaviour management, their true value lies in developing a shared understanding of why behaviours occur and how the environment, support approaches and daily occupations can be adapted to better meet the individual’s needs.
Looking Beyond the Behaviour
Following an acquired brain injury, behavioural changes are frequently linked to underlying cognitive, sensory and emotional difficulties. Executive dysfunction, impaired self-awareness, cognitive fatigue, sensory sensitivities, communication difficulties and reduced emotional regulation can all influence how a client responds to everyday situations.
As occupational therapists, our role is not simply to identify what behaviour is occurring, but to understand why it is occurring. Once we understand the underlying factors, we can begin to develop strategies to prevent, manage and reduce behaviours of concern.
For example, a client who becomes verbally aggressive during a community outing may not be demonstrating intentional aggression. The behaviour may be associated with sensory overload, fatigue, anxiety, difficulties processing information or an inability to communicate increasing distress.
Similarly, a client who repeatedly refuses support may not be lacking motivation. They may be experiencing reduced insight, cognitive overwhelm, difficulty with initiating activities or a perceived loss of control.
Understanding these contributing factors is essential if BSPs are to be effective. This approach aligns closely with Positive Behaviour Support (PBS) principles, which emphasise understanding the function of behaviour and the factors influencing it, rather than focusing solely on reducing behaviours of concern (Ponsford et al., 2021).
The Occupational Therapist Contribution to Behaviour Support Plans
Occupational therapists bring a unique perspective to behavioural support because of our focus on occupational performance and the interaction between the person, their environment and the activities they undertake.
Behaviour does not occur in a vacuum. It occurs during daily occupations, within specific environments and often in response to particular demands.
Occupational therapists are therefore well placed to identify:
- Functional triggers associated with behaviours of concern
- Environmental factors contributing to behavioural escalation
- The impact of cognitive fatigue on behaviour
- Sensory influences within home, community and workplace environments
- Occupational demands that exceed current abilities
- The relationship between routines, structure and behavioural stability
- Opportunities for meaningful occupation that support emotional regulation and wellbeing
- Effective linking activities of activities to client goals
- Appropriate grading of activities over time to match client needs
This understanding enables occupational therapists to contribute significantly to the formulation and implementation of BSPs.
Recent evidence suggests that behavioural interventions following acquired brain injury are most effective when they focus on improving activity, participation and quality of life alongside behavioural outcomes (Hendryckx et al., 2024). These are all areas in which occupational therapists have a central role.
Understanding Behaviour Through Occupational Analysis
Occupational analysis is one of the core skills occupational therapists bring to behavioural support.
Rather than viewing a behavioural incident as a standalone event, occupational therapists examine the activity being undertaken, the demands of the task, the environment, the people involved and the client’s abilities at that moment in time.
Questions may include:
- What was the person doing immediately before the behaviour occurred?
- What cognitive demands were present?
- Were there sensory triggers within the environment?
- Was fatigue a contributing factor?
- Did the individual understand what was expected of them?
- Were communication methods appropriate?
- Was the activity meaningful and motivating?
- Were support strategies consistent?
This level of analysis often reveals patterns that may otherwise be overlooked.
Behaviour frequently becomes more understandable when examined within the context of everyday occupations. This reflects the principles of Positive Behaviour Support, which advocate understanding the factors that influence behaviour and adapting supports to enable successful participation in meaningful activities, improved self-regulation and self-determination and thereby improved quality of life. (Analytis et al., 2023).
The Importance of Environment
Environmental factors are often underestimated when addressing behaviour following brain injury. Many clients experience reduced tolerance for noise, visual stimulation, difficulty with unpredictability, multitasking and social demands. Environments that were previously manageable may become overwhelming following injury.
Occupational therapists routinely assess the impact of environmental demands on occupational performance and behaviour. Research exploring Positive Behaviour Support interventions following acquired brain injury has highlighted the importance of understanding environmental influences on behaviour and adapting environments to better support participation and emotional regulation (Analytis et al., 2023).
Simple environmental adaptations can have a significant impact, including:
- Reducing sensory overload
- Increasing predictability and structure
- Modifying task demands
- Simplifying communication
- Creating supportive and enriching physical environments
- Adjusting expectations to match cognitive capacity
- Establishing consistent approaches across support teams
These adaptations do not simply reduce behavioural incidents. They can improve participation, confidence and overall quality of life.
Behaviour Support Through Meaningful Occupation
Following brain injury, individuals often experience significant occupational loss. Employment may cease, hobbies may no longer be accessible and valued life roles may change dramatically.
The resulting loss of purpose, autonomy and identity can contribute to frustration, emotional distress and behavioural difficulties.
Occupational therapists are uniquely positioned to support clients with this challenge.
By identifying meaningful and achievable occupations, occupational therapists can help clients rebuild routines, regain a sense of competence and increase opportunities for positive engagement.
Meaningful occupation can become a powerful preventative strategy within a Behaviour Support Plan.
Rather than focusing solely on reducing behaviours of concern, occupational therapists can support the development of existing or new occupations that promote wellbeing, emotional regulation and participation.
Recent literature has increasingly recognised activity and participation as important outcome measures within behavioural interventions following acquired brain injury, reinforcing the importance of meaningful occupation as a therapeutic intervention rather than simply a rehabilitation goal (Hendryckx et al., 2024).
Promoting Consistency Across Support Teams
Behaviour Support Plans are most effective when they are understood and implemented consistently by everyone involved.
Occupational therapists frequently work alongside families, support workers, case managers and other members of the multidisciplinary team to ensure behavioural strategies are practical, realistic and embedded within daily routines.
Because occupational therapists observe behaviour across real-life environments and activities, they are often able to translate clinical recommendations into functional strategies that can be applied consistently throughout a client’s day.
This practical application is often key to the success of a Behaviour Support Plan.
The Value of an Occupational Therapy Perspective
Behaviour following brain injury is complex. It is influenced by multiple factors including cognition, emotion, fatigue, sensory processing, environmental demands and occupational engagement.
While Behaviour Support Plans are frequently associated with risk reduction and behavioural management, occupational therapists bring an additional perspective. We focus on understanding how behaviour affects participation in everyday life and how changes to occupations and environments can support positive outcomes.
By identifying functional triggers, adapting environments, supporting meaningful occupation and promoting consistency across support networks, occupational therapists make an important contribution to Behaviour Support Plans following brain injury.
Through detailed occupational analysis and an understanding of the dynamic relationship between the person, their environment and their occupations, occupational therapists can help ensure Behaviour Support Plans are not only effective in reducing distress, but also support meaningful engagement in everyday life.
Ultimately, successful behavioural support is not simply about reducing behaviours of concern. It is about enabling individuals to participate more successfully in the occupations, relationships and environments that matter most to them.
References
- Analytis P, Hicks AJ, Gould KR, Feeney TJ, Ponsford JL. (2023). Clinical perspectives on delivering a Positive Behaviour Support intervention for challenging behaviours following acquired brain injury. Neuropsychological Rehabilitation, 33(2), 330–350.
- Hendryckx A, et al. (2024). Challenging behaviour, activity and participation following acquired brain injury: A scoping review. Brain Impairment, 25(1).
- Hicks AJ, Gould KR, Ponsford JL, Feeney TJ, et al. (2021). Positive Behaviour Support for adults with acquired brain injury and challenging behaviour: A review of the evidence. Brain Impairment, 22(2), 131–146.
- Ponsford JL, Hicks AJ, Gould KR, Feeney TJ, et al. (2021). _Positive Behaviour Support for challenging behaviour after acquired brain injury: An introduction to PBS+PLUS and three case studies. _Neuropsychological Rehabilitation, 31(10), 1543–1565.
Further Reading
- Scottish Acquired Brain Injury Network. Additional Interventions to Support Positive Behaviour Following Acquired Brain Injury.
- British Society of Rehabilitation Medicine (BSRM). Rehabilitation Pathways for Adults with Acquired Brain Injury.
- NICE Guideline NG252. Rehabilitation for Chronic Neurological Disorders Including Acquired Brain Injury.
- Royal College of Occupational Therapists (RCOT). Occupational Therapy in Neurological Rehabilitation.
