Clinical guideBehavioural assessment
Behavioural assessment frameworks and how clinical teams use them
Most clinical teams record behaviour long before anyone explains where the forms came from, or what the data they produce can properly support. This guide covers both, for everyone who records or uses behavioural information.
Professor Nick AldermanThe clinical content is drawn from his published work. Consultant clinical neuropsychologist and Clinical Lead at Melo. Last reviewed 9 November 2026.
01
The assessments available in Melo
Six assessment approaches are currently available in Melo. Three are published standardised instruments with psychometric research behind them. Three are structured recording formats, flexible tools whose value depends on how a team defines and records behaviour. The difference between the two groups matters when a service decides what to use, and it is explained just below.
Published standardised instruments
Agitated Behaviour Scale
ABS- What it is
- A 14-item published scale for rating agitation.
- Developed for
- Use following traumatic brain injury (Corrigan, 1989).
- Used to
- Quantify agitation and track it over repeated assessments.
- Assessment type
- Indirect. It gathers information from recollection rather than observing the behaviour as it happens.
Overt Aggression Scale–Modified for Neurorehabilitation
OAS-MNR- What it is
- A published observational recording measure for aggressive behaviour.
- Developed in
- Neurobehavioural rehabilitation (Alderman, Knight and Morgan, 1997).
- Evidence
- Reliability and validity established in its development research.
Dedicated page in preparation.
St Andrew’s Sexual Behaviour Assessment
SASBA- What it is
- A published observational recording measure for challenging sexual behaviour.
- Developed for
- People with acquired and progressive neurological impairment (Knight et al., 2008).
- In Melo
- Included with the permission of the authors and of St Andrew’s Healthcare.
Dedicated page in preparation.
Structured recording formats
ABC
Antecedent, behaviour, consequence- What it is
- Antecedent, behaviour and consequence recording, applicable to any behaviour.
- Best suited to
- The flexible starting point when a team does not yet know what it is dealing with.
- Evidence
- No published psychometric evidence. Its value depends on how a team defines and records behaviour.
Dedicated page in preparation.
ABC+
Extended ABC- What it is
- Melo’s extended ABC format.
- Records
- Positive behaviour and sleep alongside behaviours of concern, so the record covers settled periods as well as difficult ones.
Dedicated page in preparation.
ABC for learning disability and autism services
LD&A ABC- What it is
- A bespoke ABC format designed with and for learning disability and autism services.
Dedicated page in preparation.
02
Why structured behavioural observation matters
Structured behavioural observation is the practice of recording what a person does, and what was happening around them at the time, using defined categories rather than free narrative. An observer notes the behaviour itself, what came before it, and what followed, in terms agreed in advance by the team.
Narrative notes and electronic records hold a great deal of valuable information, and a well-kept record describes an admission in detail. What they rarely offer is comparability. A structured record of many events, captured the same way each time, lets a team see whether something is becoming more frequent, whether it clusters at particular times or around particular people, and whether anything they changed made a difference.
That matters because behaviour that challenges is rarely explained by one thing. Following an acquired brain injury, or in a progressive neurological condition, behaviour may be shaped by cognitive change, pain, medication, the environment, the people present, the time of day, how well someone has slept, or a need nobody has yet identified. Because the drivers vary so much between individuals, there is no universal catalogue of behaviours matched to standard interventions. Support has to be designed around the person. What can be standardised is the process of finding out.
Consider an example, invented for illustration. A man on a rehabilitation ward becomes loud and distressed one evening, and the note records the episode faithfully. Read alone, it looks unpredictable.
Across six weeks of structured records, the same behaviour appears eleven times, nine of them within half an hour of visitors leaving, and rarely on days when he slept well the night before. No single observation could have shown that.
The pattern is not an explanation in itself, but it gives the team a hypothesis worth testing.
Six weeks of structured recordsInvented example
11
Eleven episodes across six weeks. Laid out by date, they look unpredictable.
Show the episodes as a table
| Episode | Week | Day | Time | Within half an hour of visitors leaving |
|---|---|---|---|---|
| 1 | 1 | Tue | 20:10 | Yes |
| 2 | 1 | Sat | 20:22 | Yes |
| 3 | 2 | Thu | 14:10 | No |
| 4 | 2 | Sun | 20:05 | Yes |
| 5 | 3 | Wed | 20:18 | Yes |
| 6 | 3 | Fri | 20:26 | Yes |
| 7 | 4 | Mon | 20:12 | Yes |
| 8 | 4 | Sat | 22:40 | No |
| 9 | 5 | Wed | 20:08 | Yes |
| 10 | 6 | Tue | 20:15 | Yes |
| 11 | 6 | Fri | 20:28 | Yes |
03
Frameworks and instruments are not the same thing
Two quite different things are commonly called frameworks, and conflating them causes real confusion when services compare approaches or evaluate tools.
Scientific and clinical frameworks explain behaviour and guide what a clinician does about it. They are bodies of theory and method. Learning theory explains how behaviour is acquired and maintained through a person’s interaction with their environment. Applied behaviour analysis provides procedures for establishing what function a behaviour serves. Single-case experimental design provides methods for demonstrating whether an intervention has had an effect. A clinical process model governs the order in which a team does all of this, and whether it should be done at all.
Recording instruments are the tools used to capture observations. Some are published, standardised measures whose psychometric properties have been examined through research. Others are recording formats. They are structured and useful, and they have not been through that research.
The distinction is not academic. A published instrument has been studied to establish whether it measures what it claims to measure, and whether two observers recording the same event produce comparable data. A recording format has not been examined in that way. Both are worth using, and they support different kinds of claim. Knowing which you are holding matters when someone asks what your data shows.
How the assessments in Melo relate to each framework
Learning theory
Recording formats that come out of it
- ABC
- ABC+
- LD&A ABC
Learning theory explains how behaviour is acquired and maintained through a person’s interaction with their environment. The ABC recording formats come out of the operant learning framework, which is why they ask an observer to record what they saw rather than what they concluded.
Applied behaviour analysis
Indirect assessment, from recollection
- ABS
Direct assessment, recorded in real time
- OAS-MNR
- SASBA
- ABC
- ABC+
- LD&A ABC
Applied behaviour analysis supplies the procedures for establishing what function a behaviour serves. Indirect assessment gathers information without observing the behaviour as it happens, which is where the Agitated Behaviour Scale sits. Direct assessment uses formalised protocols to record behaviour in real time, and most of the instruments in Melo work that way.
The ABC formats belong to both traditions. They come out of operant learning, and ABC charting is the best known direct observation method.
Single-case experimental design
No recording instrument of its own.
Single-case experimental design provides methods for demonstrating whether an intervention has had an effect. It governs how the observations a team already holds are compared, which is covered in reviewing observations and evaluating support plans.
Clinical process model
No recording instrument of its own.
A clinical process model governs the order in which a team does all of this, and whether it should be done at all. It is set out in the clinical process, step by step.
Two of the four frameworks produce recording instruments. The other two produce none. They govern how the observations a team already holds are compared, and whether the work should be done at all.
04
Deciding whether to intervene at all
The most difficult step in behavioural work comes before any assessment, and it is the step most often skipped.
The question here is the longer-term one, whether a behaviour should become the target of a planned attempt to change it, and that decision deserves the process that follows.
Whether it is challenging at all
There are no universally agreed definitions of what constitutes challenging behaviour. When Professor Nick Alderman examined agreement among rehabilitation professionals about a range of behaviours routinely described that way in clinical practice, agreement varied considerably (Alderman, 2017).
Nearly everybody agrees that physical aggression almost always justifies intervention. Beyond that, clinicians, families and care staff frequently differ, and their differences reflect individual, professional and cultural beliefs about what is acceptable.
Insight and awareness
For a person who has sustained an acquired brain injury, the decision is further complicated by insight, awareness and capacity. Someone may not perceive their own conduct as others perceive it.
The person’s wishes, preferences and goals
What the person wants, what they prefer and the goals they hold for themselves belong in the decision, alongside the views of the team. The agreement of the team does not on its own justify intervention.
Capacity
Capacity is specific to the decision in question rather than a global judgement about the person, and neither a diagnosis nor the agreement of the team settles whether intervention is justified.
Consent, rights and the law
Consent, the person’s human rights and the legal frameworks that protect them sit around the whole process, and safeguards must be in place to uphold them.
Consistent delivery
Reaching a shared position within the team is still not a formality. A behaviour support plan has to be delivered consistently by everyone involved in the person’s care, whenever it is required. Where members of the team were never persuaded that the behaviour warranted intervention, delivery becomes inconsistent, and inconsistent delivery undermines the plan. It can increase the frequency and severity of the behaviour rather than reduce it.
One thing this question does not do is delay keeping people safe. Responding in the moment to protect the person or others is simply care.
05
The clinical process, step by step
Once a team agrees that intervention is warranted, the remaining steps are more straightforward to work through. What follows is a simplified account of the process model Professor Alderman has described in full elsewhere (Alderman, 2024a).
Before anything else
Is this behaviour actually challenging, and is it right to try to change it?The step most often skipped. Keeping people safe in the moment is simply care. This decision is about whether a behaviour should become the target of a planned attempt to change it.
Evaluation is not the end of the line. What the team sees after the plan begins feeds back into the formulation and leads to revisions.
Assessment
Assessment draws on several sources. The person’s social, educational and medical history. An understanding of their neurocognitive functioning. Interviews with the person, their family and the staff responsible for their care. Questionnaire measures. And, most instructively, direct observation of the behaviour as it occurs.
Formulation
Formulation is where that information becomes a working explanation. The team generates hypotheses about the causes of the behaviour, what precipitates it and what maintains it (Eells, Kendjelic and Lucas, 1998). Observational data is considered alongside research on the clinical condition and the experience and judgement of the clinicians involved.
Where a team is working from learning theory, formulation centres on the function the behaviour serves for that individual and the need its expression fulfils.
The behaviour support plan
The behaviour support plan follows from the formulation and from the clinical approach the service works within. Everyone delivering care must understand the plan and be prepared to deliver it consistently. The plan should carry goals, so that there is a point at which the team can consider withdrawing the intervention or turning to other needs.
Evaluation
Evaluation is continuous. Observation does not stop when the plan begins, because what the team sees after the plan starts feeds back into the formulation and leads to revisions.
Generalisation and maintenance
Generalisation and maintenance come last, once goals are met. Gains made in one setting do not transfer automatically to others, and they are not automatically held.
06
The science behind the instruments
Anyone using a structured behavioural instrument is using a tool that came out of a particular scientific tradition, and understanding that tradition changes how the resulting data is read. Each foundation is summarised below, with the full account a click away, or carry on to ABC recording and standardised measures.
- Positive behaviour support
- Neurobehavioural rehabilitation
Learning theory
Behaviour is shaped by its consequences. Reinforcement increases the likelihood of a behaviour, punishment reduces it.
- Associated with
- Operant learning and B. F. Skinner.
- Why it matters here
- It is why the forms ask an observer to record what they saw rather than what they concluded.
- In Melo
- The ABC recording formats come out of this framework.
Theories of learning describe how new knowledge and skills are acquired, and generate principles that can be applied to reduce behaviour that challenges. The most influential for this work is operant learning, associated with B. F. Skinner, which demonstrated that behaviour is shaped by its consequences. Reinforcement increases the likelihood of a behaviour, punishment reduces it.
These principles informed the behaviour modification movement of the latter half of the twentieth century, and coincided with a broader move towards scientific method in psychiatric medicine, including objective measurement of whether an intervention had worked. The measurement tools used in structured behavioural observation derive directly from this framework. It is why they ask an observer to record what they saw rather than what they concluded.
Recorded as it happensRecalled afterwards
Applied behaviour analysis
Establishes what function a behaviour serves for a particular person.
- Two methods
- Indirect assessment works from recollection. Direct assessment records behaviour in real time.
- Why it matters here
- A plan built on function can meet that need in a more acceptable way, often by teaching an alternative strategy.
- In Melo
- The Agitated Behaviour Scale is an indirect measure. Most of the instruments in Melo work directly (Alderman, 2024b).
Applied behaviour analysis superseded behaviour modification. Where behaviour modification largely applied consequences known in a general sense to influence behaviour, applied behaviour analysis is concerned with individual assessment, and with determining the functional relationship between a particular person’s behaviour and their environment (Cooper, Heron and Heward, 2020).
Establishing the contribution of both antecedents and consequences allows a team to arrive at a view about what function the behaviour serves. A plan built on function can meet that need in a more acceptable way, often by teaching an alternative strategy, and it will almost always be more focused than a plan built on consequences alone.
Two methods, directly relevant here
Indirect functional behavioural assessment gathers information without observing the behaviour as it happens, through clinical notes, interviews and proxy questionnaire measures completed from recollection. Measures of this kind include the Overt Behaviour Scale (Kelly et al., 2006), the St Andrew’s–Swansea Neurobehavioural Outcome Scale (Alderman, Wood and Williams, 2011), and the Agitated Behaviour Scale (Corrigan, 1989). Of those three, only the Agitated Behaviour Scale is available in Melo.
Direct functional behavioural assessment uses formalised observation protocols to record behaviour in real time, which avoids the recall problems of retrospective report. Most of the instruments in Melo work this way (Alderman, 2024b).
One further point
Learning theory and applied behaviour analysis explain behaviour and supply methods, and the shape a support plan actually takes depends on the clinical approach the service works within. Positive behaviour support and neurobehavioural rehabilitation both evolved out of this tradition, and plans produced under each can look quite different (Mooney, Brooks and Diggin, 2024).
07
ABC recording and standardised measures
The best known direct observation method is the ABC chart. The observer records what happened immediately before the behaviour, the behaviour itself, and what happened after it.
- AAntecedentWhat happened immediately before the behaviour.
- BBehaviourThe behaviour itself, as the observer saw it.
- CConsequenceWhat happened after it.
ABC recording is popular for good reason. It is flexible, it applies to any behaviour, and it is the sensible starting point when a team does not yet know what it is dealing with.
Its weakness is the same flexibility. An ABC chart cannot by itself guarantee that two observers watching the same event will record the same thing, because it does not constrain what they write. One member of staff records that a patient became aggressive. Another records that he raised his voice when asked to move from a chair. Only the second can be compared with anything.
None of this means ABC data is doomed to be unusable. A service with agreed operational definitions and trained observers can run ABC recording that supports genuinely useful analysis. The format does not enforce that discipline. The team supplies it, which is why definitions are worth the training time.
A usable observation describes what a person did in terms another observer would recognise, without attributing a cause or a motive.
-
An observation
Shouted and pushed a chair over when the medication trolley arrived
Describes what the person did, in terms another observer would recognise. It can be counted.
-
An interpretation
Was difficult about his medication
Attributes a motive. It cannot be counted, and two observers will not record it the same way.
The same problem is visible in the research literature, where reported rates of aggression following brain injury vary widely between studies. That variation has been attributed in part to researchers working from different definitions, some operational and observable, others resting on internal states such as irritability, and some counting only one category of aggression.
Observational recording measures were developed in response to the limitations of open-ended recording. These are published instruments whose psychometric properties have been examined, so a team knows how reliably and validly the instrument measures when used as designed (Girard and Cohn, 2016). The observer chooses from standardised lists in which every item is operationally defined, and behaviour is assigned to categories or rated on continuous dimensions, which turns observation into a quantitative judgement that can be compared across observers, shifts and months.
The psychometric evidence belongs to the instrument, and it was established under the conditions of the development research. It tells a team the tool is capable of producing reliable data when used properly. It does not guarantee the quality of any individual record, which still depends on training, time and the conditions on the ward.
ABC recording and observational recording measures compared
Four differences that decide which one answers your question
| Compared on | ABC recording | Observational recording measures |
|---|---|---|
| Applies to | Any behaviour | The specific behaviours the measure covers |
| Response options | Open, shaped by the team’s definitions | Standardised, each item operationally defined |
| Published psychometric evidence | No | Yes, for the instrument as developed |
| Best suited to | Early exploration, any presentation | Precise measurement of a defined behaviour |
A standardised measure gives dependable data about the behaviours it covers, and nothing at all about the behaviours it does not. This is why most services use a standardised measure alongside a flexible recording format rather than choosing between the two.
Two measures in Melo
The Overt Aggression Scale–Modified for Neurorehabilitation measures aggressive behaviour, with reliability and validity established in its development research (Alderman, Knight and Morgan, 1997).
The St Andrew’s Sexual Behaviour Assessment measures challenging sexual behaviour in people with acquired and progressive neurological impairment (Knight et al., 2008), and is included with the permission of the authors and of St Andrew’s Healthcare.
08
Reviewing observations and evaluating support plans
Between recording an observation and acting on it sits a chain of distinct steps, and keeping them distinct is what makes behavioural evidence trustworthy. Observing behaviour. Recording it so it can be compared. Formulating hypotheses about function. Designing support around those hypotheses. Reviewing what happens next. And, where it matters, establishing whether the support actually caused the change.
Most teams review a plan through before and after comparison. The behaviour was recorded for a period before the plan began, the same observations continue afterwards, and the two phases are compared (Barlow, Nock and Hersen, 2008). That is monitoring, and it is genuinely useful. On its own it does not establish cause, because behaviour fluctuates, and other things change at the same time as a plan is introduced, staffing and medication among them.
Establishing cause takes a stronger design, and this is where single-case experimental methods come in. Scientific convention labels baseline conditions A and successive interventions B, C and so on. In a reversal design, the intervention is withdrawn for a second baseline and then reintroduced. Where the behaviour changes only when the intervention is in place, the case that the intervention is responsible becomes considerably stronger.
Withdrawing support that appears to be working raises obvious ethical questions, and for some behaviours it is not acceptable. Other designs avoid withdrawal, notably multiple-baseline approaches, which introduce the intervention at different points across behaviours, settings or individuals (Barlow, Nock and Hersen, 2008).
The practical foundation for any of this is the baseline. Without observations recorded before a plan begins, there is nothing to compare against, and the question of whether the plan worked cannot be answered later.
- Observe
- Record
- Formulate hypotheses
- Design support
- Review
- Establish cause
A step that involves interpretation
Before and afterInvented data
Baseline, as recordedWith the plan, as recordedPlan beginsOther changes that could explain the fall
Show the weekly counts as a table
| Week | Phase | Episodes | Other change |
|---|---|---|---|
| 1 | Baseline (A) | 7 | |
| 2 | Baseline (A) | 8 | |
| 3 | Baseline (A) | 6 | |
| 4 | Baseline (A) | 9 | |
| 5 | Baseline (A) | 7 | |
| 6 | Plan in place (B) | 5 | Plan begins. Staffing changed |
| 7 | Plan in place (B) | 4 | Medication reviewed |
| 8 | Plan in place (B) | 4 | |
| 9 | Plan in place (B) | 3 | |
| 10 | Plan in place (B) | 3 | |
| 11 | Plan in place (B) | 2 | |
| 12 | Plan in place (B) | 3 |
Multiple baselineInvented data
BeforeAfter the plan starts there
Show as a table
| Setting | Plan starts | Wk 1 | Wk 2 | Wk 3 | Wk 4 | Wk 5 | Wk 6 | Wk 7 | Wk 8 | Wk 9 | Wk 10 |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Setting 1 | Week 4 | 6 | 7 | 6 | 4 | 3 | 3 | 2 | 2 | 2 | 1 |
| Setting 2 | Week 6 | 5 | 6 | 5 | 6 | 6 | 3 | 3 | 2 | 2 | 2 |
| Setting 3 | Week 8 | 7 | 6 | 7 | 6 | 7 | 6 | 7 | 4 | 3 | 3 |
09
How Melo supports structured observation
Melo counts and lays out what staff record. The clinical team does the reading.
Melo is the platform this guide’s assessments live in, so it is worth being concrete about what Melo actually does.
Recorded at the point of care
Observations go in as they happen
Ward and care staff record structured behavioural observations as they happen, using the published instruments and recording formats described above.
- 1Note 1. Assessments recorded in the previous 48 hours, by instrument.
- 2Note 2. Each person’s recent behaviours, grouped by severity rating.
One shared record, over time
Weeks of records in one place
Observations made by different staff across different shifts build one record, presented over time, so a multidisciplinary team can review weeks or months rather than reconstructing them from separate notes.
Key events, such as the introduction of a behaviour support plan, can be marked on those charts, which is what makes the before and after comparison described above possible in day-to-day practice.
- 1Note 1. Negative and positive behaviours plotted together, with average severity.
- 2Note 2. Totals for the period and the most recent severity.
Laid out by time
The same question as the six-week example
Melo can lay recorded behaviour out by time of day and day of the week, the same view as the six-week example. Why behaviour concentrates where it does is for the team to work out.
- 1Note 1. Counts for each two-hour block and day.
- 2Note 2. Totals for the period.
Interpretation stays where it belongs
Melo records, calculates and displays behavioural information for the clinical team. Melo applies only the rule-based scoring already inherent in each paper instrument, without altering thresholds or adding interpretation.
Melo does not diagnose, does not determine the function of a behaviour, and does not recommend or decide anything.
To see what this looks like in a working service, the University Hospitals of Liverpool Group case study describes how ward teams across an acute trust record and review behavioural observations in Melo, including through periods of enhanced observation.
Read the Liverpool case study10
What behavioural records can and cannot tell you
A structured record is evidence about what was observed. Treating it as more than that is the commonest error in this field, and clinicians are better served by knowing the limits.
A record showing that a behaviour followed a particular antecedent on twelve occasions is correlational evidence. It supports a hypothesis about function. Establishing cause requires the designs described above, and even then the finding concerns that individual in that setting.
Monitoring shows that something changed. It takes design, and judgement, to say why.
It shows that recording has embedded in practice. On its own it says nothing about whether anybody is better off.
Most of the measures discussed here were developed in specialist neuro-behavioural inpatient services. Applying them in dementia care, learning disability services or acute wards is often reasonable and widely done. It extends their original validation rather than resting on it.
11
Further learning and clinical resources
Where structured behavioural observation has been written up by the services using it, and where Melo’s clinical safety and data protection position is set out in full.
-
Case study
Behavioural observation across an acute NHS trust
How ward teams at University Hospitals of Liverpool Group record and review behavioural observations, including through periods of enhanced observation.
Read the case study -
Service evaluation
A one-year evaluation in specialist neurorehabilitation
The Royal Hospital for Neuro-disability, Putney, with a one-year service evaluation and an implementation study behind it.
Read the case study -
Patient story
Reading a record to understand one person’s distress
How a clinical team at The Oakleaf Group read the patterns in a patient’s recorded observations and built three changes into his behaviour support plan.
Read the patient story -
Clinical guide
Enhanced therapeutic observations
How teams review observations through periods of enhanced observation, and what NHS England’s ETOC programme asks of trusts.
Read the guide -
Governance
Clinical safety, data protection and regulatory position
DTAC, DCB0129, the Data Security and Protection Toolkit, Cyber Essentials, and Melo’s position under UK medical device regulation.
Go to the governance hub
12
About the clinical authority behind this guide
The clinical content of this guide is drawn from Professor Alderman’s published work on the assessment and management of behaviour that challenges following acquired brain injury.
Professor Nick Alderman
Clinical Lead at Melo, consultant clinical neuropsychologist
Professor Nick Alderman specialises in the assessment and management of behaviour that challenges following acquired brain injury.
- Co-author of the Overt Aggression Scale–Modified for Neurorehabilitation
- Co-author of the St Andrew’s Sexual Behaviour Assessment
- Co-author of the St Andrew’s–Swansea Neurobehavioural Outcome Scale
- Co-editor of Managing Challenging Behaviour Following Acquired Brain Injury (Routledge, 2024)
Common questions
No, and it is not intended to be. ABC recording is a structured format for capturing observations rather than a standardised instrument with published psychometric evidence. That is what makes it flexible enough to apply to any behaviour, and it means the quality of the data depends on the team’s operational definitions and training.
No. Melo brings recorded observations together and presents them so that a clinical team can review them. Identifying the function of a behaviour is a clinical judgement, reached through formulation, using the recorded information alongside history, cognitive assessment and everything else the team knows about the person.
You can build a reasonable case. That requires a baseline recorded before the plan started, the same observations continuing afterwards, and a record of when the plan was introduced. Without a baseline there is nothing to compare against, which is the commonest reason this question cannot be answered later. Showing that the plan caused the change is a stronger claim and needs the designs described in this guide.
That depends on the population, on what the team already uses, and on what they are trying to understand, so it is a clinical decision rather than a software one. As a general principle, a service that does not yet know what it is dealing with is usually better served by starting with flexible recording and introducing a standardised measure once the behaviours of interest are clear.
- Alderman, N. (2001). Management of challenging behaviour. In R.Ll. Wood and T. McMillan (Eds.), Neurobehavioural Disability and Social Handicap Following Traumatic Brain Injury. Hove: Psychology Press.
- Alderman, N. (2002). Individual case studies. In S. Priebe and M. Slade (Eds.), Evidence in Mental Health Care. Hove: Brunner-Routledge.
- Alderman, N. (2017). Interventions for challenging behaviour. In T. McMillan and R.Ll. Wood (Eds.), Neurobehavioural Disability and Social Handicap Following Traumatic Brain Injury (2nd ed.). Routledge.
- Alderman, N. (2024a). The intervention model: frameworks, principles, and practice. In N. Alderman and A. Worthington (Eds.), Managing Challenging Behaviour Following Acquired Brain Injury. Abingdon: Routledge.
- Alderman, N. (2024b). Determining the cause: recording behaviour using direct observation methods. In N. Alderman and A. Worthington (Eds.), Managing Challenging Behaviour Following Acquired Brain Injury. Abingdon: Routledge.
- Alderman, N., Knight, C. and Henman, C. (2002). Aggressive behaviour observed within a neurobehavioural rehabilitation service: utility of the OAS-MNR in clinical audit and applied research. Brain Injury, 16(6), 469–489.
- Alderman, N., Knight, C. and Morgan, C. (1997). Use of a modified version of the Overt Aggression Scale in the measurement and assessment of aggressive behaviours following brain injury. Brain Injury, 11(7), 503–523.
- Alderman, N., Wood, R.Ll. and Williams, C. (2011). The development of the St Andrew’s–Swansea Neurobehavioural Outcome Scale: validity and reliability of a new measure of neurobehavioural disability and social handicap. Brain Injury, 25(1), 83–100.
- Barlow, D.H., Nock, M.K. and Hersen, M. (2008). Single Case Experimental Designs: Strategies for Studying Behavior Change (3rd ed.). New York: Allyn & Bacon.
- Bijou, S.W., Peterson, R.F. and Ault, M.H. (1968). A method to integrate descriptive and experimental field studies at the level of data and empirical concepts. Journal of Applied Behavior Analysis, 1(2), 175–191.
- Cooper, J.O., Heron, T.E. and Heward, W.L. (2020). Applied Behavior Analysis (3rd ed.). Harlow: Pearson.
- Corrigan, J.D. (1989). Development of a scale for assessment of agitation following traumatic brain injury. Journal of Clinical and Experimental Neuropsychology, 11(2), 261–277.
- Eells, T.D., Kendjelic, E.M. and Lucas, C.P. (1998). What’s in a case formulation? Journal of Psychotherapy Practice and Research, 7(2), 144–153.
- Girard, J.M. and Cohn, J.F. (2016). A primer on observational measurement. Assessment, 23(4), 404–413.
- Johnson, C., Knight, C. and Alderman, N. (2006). Challenges associated with the definition and assessment of inappropriate sexual behaviour amongst individuals with an acquired neurological impairment. Brain Injury, 20(7), 687–693.
- Kelly, G., Todd, J., Simpson, G., Kremer, P. and Martin, C. (2006). The Overt Behaviour Scale (OBS): a tool for measuring challenging behaviours following ABI in community settings. Brain Injury, 20(3), 307–319.
- Knight, C., Alderman, N., Johnson, C., Green, S., Birkett-Swan, L. and Yorston, G. (2008). The St Andrew’s Sexual Behaviour Assessment (SASBA): development of a standardised recording instrument for the measurement and assessment of challenging sexual behaviour in people with progressive and acquired neurological impairment. Neuropsychological Rehabilitation, 18(2), 129–159.
- Mooney, P., Brooks, J. and Diggin, N. (2024). Behaviour support in the context of neurobehavioural rehabilitation. In N. Alderman and A. Worthington (Eds.), Managing Challenging Behaviour Following Acquired Brain Injury. Abingdon: Routledge.
- Sabaz, M., Simpson, G.K., Walker, A.J., Rogers, J.M., Gillis, I. and Strettles, B. (2014). Prevalence, comorbidities, and correlates of challenging behaviour among community-dwelling adults with severe traumatic brain injury: a multicenter study. Journal of Head Trauma Rehabilitation, 29(2), E19–E30.
See how clinical teams use structured behavioural observation in practice
Our case studies set out what two services did and what changed.
Published instrument
The Agitated Behaviour Scale (ABS)
The Agitated Behaviour Scale is a 14-item published scale for rating agitation, developed for use following traumatic brain injury (Corrigan, 1989). It gives a clinical team a way to put a number on agitation and to track that number over repeated assessments.
This page covers what the scale measures, where it sits among the behavioural assessment frameworks the other instruments come from, what its published evidence does and does not support, and how the scale works in Melo.
01
What the Agitated Behaviour Scale is
The Agitated Behaviour Scale is a published standardised instrument. It was developed for use following traumatic brain injury and consists of 14 items, each rated by an observer (Corrigan, 1989).
Its purpose is quantification. Agitation after a brain injury is described in ward notes in a great many different ways, and those descriptions cannot be added up or compared. A rating scale turns the same observations into a figure, and a figure recorded the same way each time can be compared against the last one.
That is what makes repeated assessment useful. Reassessment after a period of time supports conclusions about whether an intervention has helped, through a reduced score compared with the initial assessment.
The Agitated Behaviour Scale measures agitation. It does not explain what is causing it, and it is not a diagnosis.
02
Where the ABS sits among the frameworks
Behavioural assessment splits into two broad approaches, and the Agitated Behaviour Scale sits firmly in one of them. Knowing which changes how its results should be read.
Indirect and direct functional behavioural assessment
Two methods within applied behaviour analysis
| Compared on | Indirect assessment, including the ABS | Direct assessment |
|---|---|---|
| How information is gathered | Without observing the behaviour as it happens, through clinical notes, interviews and proxy measures completed from recollection | Through formalised observation protocols, recording behaviour in real time |
| Main limitation | Depends on what the rater remembers | Depends on an observer being present and trained |
| Instruments in Melo | Agitated Behaviour Scale | OAS-MNR, SASBA, and the ABC recording formats |
Because the Agitated Behaviour Scale is completed from recollection rather than at the moment the behaviour occurs, it is usually used alongside a direct method rather than instead of one (Alderman, 2024b).
Two other measures of the same indirect kind appear in the literature and are worth knowing about, though neither is available in Melo. They are the Overt Behaviour Scale (Kelly et al., 2006) and the St Andrew’s–Swansea Neurobehavioural Outcome Scale (Alderman, Wood and Williams, 2011).
The frameworks these methods come from, and the clinical process they sit inside, are set out in the guide to behavioural assessment frameworks.
03
What the published evidence supports, and what it does not
The Agitated Behaviour Scale is a published instrument whose psychometric properties have been examined. That is a real advantage over an open recording format, and it is worth being precise about what it buys a team.
Published psychometric evidence tells a team the tool is capable of producing reliable data when it is used as designed, under the conditions of the development research. It does not guarantee the quality of any individual record, which still depends on training, time and the conditions on the ward.
A reduced score at reassessment supports a conclusion about whether an intervention has helped. Establishing that the intervention caused the change is a stronger claim, and it needs a baseline recorded beforehand and one of the single-case designs described in the pillar guide.
The Agitated Behaviour Scale was developed for use following traumatic brain injury. Applying it in dementia care, learning disability services or on acute wards is often reasonable and widely done. It extends the original validation rather than resting on it.
04
The Agitated Behaviour Scale in Melo
Melo digitises the scale. It does not change it.
Melo includes the scale as a calculator. It performs the arithmetic already inherent in the paper instrument, without altering thresholds and without adding interpretation.
Successive assessments for the same person build one record, presented over time, so a reduced score at reassessment can be read against what came before it rather than recalled.
Assessments completed by different staff sit in the same record, so a multidisciplinary team reviews one history rather than reconstructing it from separate notes.
Interpretation stays where it belongs
Melo records the ratings an observer gives, calculates the score the paper scale would give, and displays the result for the clinical team.
Melo does not diagnose, does not determine the function of a behaviour, and does not recommend or decide anything.
The Agitated Behaviour Scale is one of six assessments in Melo
The guide to behavioural assessment frameworks sets out all six, and the clinical frameworks they come from.