Understanding Behaviour Through Pain That Is Hard to Communicate in PBS

Positive Behaviour Support requires services to understand how pain can affect behaviour, communication and emotional regulation. The Positive Behaviour Support knowledge hub supports providers to connect behaviour, communication, proactive support, rights and reduction of restrictive practice.

In specialist services, understanding behaviour through PBS means asking whether discomfort, injury, dental pain, constipation, infection, reflux, headaches, menstrual pain or musculoskeletal pain may be affecting presentation.

This reflects PBS principles and values, because support should protect wellbeing and dignity. Strong services do not interpret sudden distress, refusal or aggression without considering pain and health communication.

Concept Explained Clearly

Pain can be difficult to identify when someone cannot describe what hurts, where it hurts or how severe it feels. Some people may show pain through movement, facial expression, posture, sleep change, appetite change, touch sensitivity or behaviour that appears unrelated.

Behaviour linked to pain may include refusing personal care, pushing people away, withdrawing, crying, becoming aggressive when touched, avoiding movement, changes in eating, sleep disruption or sudden distress during usual routines. In PBS, these behaviours should be understood as possible communication that the body feels unsafe or uncomfortable.

Why It Matters in Real Services

If pain is missed, services may respond with behavioural strategies when the person needs health assessment, treatment or adjusted support. This can increase distress and delay care.

The practical consequences can be serious. People may experience untreated pain, increased incidents, reduced participation and loss of trust in support. Commissioners and CQC will expect providers to evidence that health-related behaviour is recognised, recorded and escalated appropriately.

What Good Looks Like

Strong services demonstrate that pain is actively considered when behaviour changes. Staff know the person’s usual presentation, pain indicators, health risks and communication style.

Good PBS practice uses pain profiles, baseline records, body maps, health action plans, family insight, clinical liaison and behaviour monitoring. Providers should be able to evidence how health review changes support and improves wellbeing.

Operational Example 1: Refusal of Personal Care Linked to Shoulder Pain

Step 1 – Routine change identified: A person in supported living began refusing upper-body washing and became distressed when staff offered help with dressing.

Step 2 – Pain possibility explored: Staff noticed the person guarded one shoulder, avoided lifting their arm and slept in a different position.

Step 3 – Support approach: The provider paused assumptions about refusal and arranged health review while adapting the personal care routine.

Step 4 – Day-to-day delivery detail: Staff offered loose clothing, supported washing from the unaffected side first and avoided raising the arm until reviewed.

Step 5 – How effectiveness was evidenced: Health review confirmed shoulder pain. Distress reduced after treatment and adapted support. The provider evidenced that behaviour was linked to physical discomfort, not refusal of care.

Deepening the Understanding: Behaviour May Be the Pain Report

Some people will not say “I am in pain.” Their behaviour may be the clearest report available. A change in tolerance, movement, sleep or appetite should prompt curiosity before behavioural conclusions are made.

Strong providers should be able to evidence how staff distinguish known behavioural patterns from new or unusual presentation. Pain should be considered especially when behaviour changes suddenly, appears during touch or movement, or occurs alongside health changes.

The article on seeing behaviour as communication in PBS reinforces why sudden changes in behaviour should be read as meaningful communication, including possible communication about pain.

Operational Example 2: Mealtime Distress and Dental Pain

Step 1 – Eating pattern reviewed: In a residential service, a person began refusing crunchy foods and became distressed at mealtimes.

Step 2 – Health clues gathered: Staff noticed chewing on one side, increased dribbling and hand-to-face movements after meals.

Step 3 – Support adjusted: The provider arranged dental review and temporarily offered softer food choices without framing the change as behaviour management.

Step 4 – Practical delivery: Staff monitored food tolerance, recorded facial expressions and avoided pressuring the person to finish meals.

Step 5 – Outcome evidence: Dental treatment reduced mealtime distress, appetite improved and food refusal decreased. The provider evidenced a clear link between pain identification, health action and behavioural outcome.

Systems, Workforce and Consistency

Pain-related behaviour requires joined-up systems. Staff need clear routes for recording health concerns, escalating changes, sharing family insight and reviewing whether support plans need adjustment.

Strong services include pain indicators in PBS plans, health action plans, communication profiles and handovers. Supervision should review whether staff are curious about pain when behaviour changes, rather than defaulting to existing behavioural explanations.

Operational Example 3: Night Distress Linked to Constipation

Step 1 – Pattern recognised: A person began waking at night, pacing and pressing their abdomen. Daytime behaviour also became more irritable.

Step 2 – Physical pattern reviewed: Bowel records were incomplete, but staff identified reduced bowel movements, reduced appetite and discomfort when sitting.

Step 3 – Support response: The provider completed bowel monitoring, sought clinical advice and reviewed food, fluid and movement routines.

Step 4 – Delivery detail: Staff used a discreet body-comfort chart, increased fluid prompts and recorded sleep, appetite and bowel patterns consistently.

Step 5 – Evidence reviewed: Clinical intervention improved bowel regularity, night waking reduced and daytime irritability decreased. The provider evidenced that physical discomfort had been driving behavioural change.

Governance and Evidence

Governance should show how pain-related behaviour is identified, escalated and reviewed. Providers should be able to evidence pain profiles, health action plans, body maps, bowel records, sleep charts, incident analysis, clinical liaison, family input and PBS plan updates.

Strong governance connects behaviour to health action. Records should show what changed, what pain indicators were present, what assessment was sought, what support changed and whether outcomes improved. This creates a clear line of sight from behaviour to possible pain, from pain indicators to health action, and from health action to improved wellbeing.

Commissioner and CQC Expectations

Commissioners expect providers to understand behaviour in relation to health, communication and quality of life. They need assurance that people are not left in avoidable pain because behaviour is interpreted too narrowly.

CQC will expect care to be safe, responsive and person-centred. Inspectors may review whether health concerns are recognised, whether records are accurate, whether advice is sought and whether plans change following learning. Strong services demonstrate that pain is always considered when behaviour changes.

Common Pitfalls

• Assuming known behaviour has the same cause every time.
• Missing pain because the person cannot describe it verbally.
• Recording refusal without reviewing touch, movement, sleep or appetite changes.
• Failing to maintain bowel, pain or health monitoring records.
• Using behavioural strategies before health causes are explored.
• Not updating PBS plans after health-related learning.

Conclusion

Understanding behaviour through pain helps PBS teams recognise that distress may be the person’s clearest health communication. Behaviour may communicate discomfort, fear of touch, movement difficulty or untreated physical need.

Strong providers treat health curiosity as part of PBS. They evidence how observation, escalation, treatment and adapted support reduce distress and improve quality of life. This gives commissioners and CQC confidence that behaviour is understood safely, respectfully and in the context of the whole person.