The use of appropriate language: ‘Behavioural Expressions of Need’

Reference: Marshall, J., Stapleton, S., Lamers, C. and James, C. (2026) ‘The Use of Appropriate Language: ‘Behavioural Expressions of Need’’, Journal of Dementia Care, 34(1) pp. 24-28.

The language we use is fundamental to how we understand, describe and respond to the effects of dementia on a person. In this article, Dr Joanna Marshall and colleagues propose a significant change in language, and invite everyone supporting or caring for people living with dementia, paid or unpaid, to use this new and important terminology.

There is widespread disagreement and dissatisfaction with the terminology used to describe behaviours viewed as “problematic” or “disruptive”, often labelled as agitation or aggression. The terms ‘challenging behaviour’ and ‘behaviours that challenge’, which were previously widely used, have increasingly become associated with the more biomedical term ‘Behavioural and Psychological Symptoms of Dementia’ (BPSD). The latter term has been particularly unpopular and even prompted the social media campaign #BanBPSD. Language directly influences the support offered to people living with dementia and their families. It is therefore timely to change the language used and to instil hope that non-pharmacological interventions can be effective.

Background

In 2018, the British Psychological Society (BPS) funded a programme to develop best-practice guidelines focusing on interventions for people living with dementia who experience behaviour that challenges. In the same year, the updated NICE guidelines, ‘Dementia: Assessment, management and support for people living with dementia and their carers’ (2018), were published and also used this terminology.    

The BPS programme included a review of terminology, beginning with a one-day consultation event involving a range of professionals and stakeholders. Written feedback from 74 individuals informed the development of an online survey.  This was cascaded through multi-professional groups and completed by 378 multidisciplinary professionals and stakeholders, including experts who had published in peer reviewed journals. The survey explored preferences for alternative terminology. Opinions were divided between biomedical or psychiatric language, which framed behaviours as “symptoms” of dementia, and psychosocial language, which emphasised other reasons to explain why a person living with dementia may act as they do (Wolverson et al., 2019). Biomedical terms were perceived as avoiding negative connotations of “misbehaviour,” while psychosocial terms were seen as supporting understanding of behaviours as normal reactions to frightening or frustrating situations.

The views of people living with dementia

Further research sought the views of people living with dementia themselves (Wolverson et al., 2021). Although no single term achieved consensus, ‘unmet needs’ was most frequently ranked as a preferred concept. Participants explained this preference by noting that “my behaviour is a way of signalling that something is wrong” and that “people should be asking why”. In contrast, the terms ‘challenging behaviour’ and ‘behaviour that challenges’ were often described as blaming, with participants stating that such terms “blame the person and suggest they are being challenging”.

Good practice guidelines on how we talk about dementia were co-produced by a review panel of people living with dementia working alongside Innovations in Dementia (Bachelor et al., 2023). These were shared by Emma Hewat, Head of Dementia at the care home group KYN, at Dementia Congress 2024. The review panel highlighted that many terms used in healthcare settings, such as ‘behaviour that challenges’ and ‘behavioural and psychological symptoms of dementia’ (BPSD), can have the effect of othering and dehumanising people living with dementia. The panel recommended avoiding these terms in favour of alternative ways of thinking, such as a focus on ‘unmet needs’.

Wolverson et al (2022) also explored the views of family carers, who expressed a preference for the concept of ‘behavioural expressions of need’, a term that few had encountered previously; this term emerged from work conducted by James et al (2024). In the Wolverson survey family carers felt that ‘BPSD’, ‘challenging behaviour’, and ‘behaviours that challenge’ should be avoided.

Vote at UK Dementia Congress 2024

A vote on adopting a new term to replace ‘challenging behaviour’ was held at the UK Dementia Congress in 2024. Professor Ian James (Consultant Clinical Psychologist at Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, and Honorary Visiting Professor at the University of Bradford) chaired a panel discussion, outlining the requirements of an effective term (see Table 1), before asking participants to vote for their top three preferred terms using a ballot system (see Table 2).

Prior to the vote, several issues were debated by panel members and participants. Three key topics emerged:

• the concept of unmet need,
• the use of the word behaviour, and
• concerns about acronyms.

These issues are briefly discussed below, followed by the voting results.

(i) Needs to be met

There was broad agreement among the panel and audience that any new term should include the word “need” to ‘find the why’ of the behaviour (see Jenks et al., 2024). A needs-based perspective proposes that unmet physical or psychological needs contribute to behaviours, which represent attempts by a person living with dementia to maintain wellbeing or reduce distress. However, concerns were raised about the lack of consensus regarding what constitutes a need.

As part of this discussion, the 8-Needs Framework was considered. This framework supports understanding individual needs and provides a focus for non-pharmacological interventions. This work was described in the Journal of Dementia Care by Marshall and Thwaites (2024). Drawing on Kitwood’s Flower (1997) and Maslow’s Hierarchy of Needs (1943), the model is based on the principle that needs are universal, regardless of whether a person is living with dementia. The eight identified needs are: physical comfort and freedom from pain; safety; positive touch; love and belonging; esteem; control over environment and possessions; occupation and exploration; and fun. Wellbeing is sustained through the meeting of these needs, and when they are unmet – such as when individuals feel unsafe, disrespected, or lacking control – distress or ‘behavioural expressions of need’ may emerge.

(ii) Use of the word ‘behaviour’

Concerns were raised about continuing to use the word ‘behaviour’, as it can imply fault, intention, or ‘misbehaviour’. During the panel discussion, Professor Graham Stokes (Director of Dementia and Specialist Service Innovation at HC-One and Honorary Visiting Professor of Person-Centred Dementia Care at the University of Bradford) argued that any new terminology should retain the word behaviour in order to maintain a focus on observable actions, that can be described to others.

(iii) Avoiding problematic acronyms

During the 2024 discussions, it was noted that people living with dementia have repeatedly asked professionals to avoid confusing acronyms. James et al (2021) conducted focus groups to explore the term ‘Behavioural and Emotional Expressions of Need’. Concerns were raised about its length and the likelihood that it would be shortened to the acronym ‘BEEN’. Some participants felt this was too close to the phrase “has been” and implied decline. As a result, many favoured the shorter alternative ‘Behavioural Expressions of Need’. This was considered concise enough to avoid abbreviation; however, if an acronym were required, ‘BEN’ was viewed as acceptable.

Results

The voting results are presented in Table 3 above. Participants ranked their top three preferred terms from a list of nine (see Table 2), drawn from previous research. First-choice terms were awarded three points, second-choice terms two points, and third-choice terms one point. As shown in the results, ‘Behavioural Expressions of Need’ was clearly the most preferred term overall and was the top choice across all professional groups, apart from trainers.

Proposal by the Association of Clinical Psychologists-UK

The authors consider the use of appropriate terminology to be critically important. The January 2025 edition of the Journal of Dementia Care (Davies-Abbott and Roberts, 2025; Hewat, 2025) highlighted how certain terms used when writing and speaking about people living with dementia can be stigmatising and detrimental to care. The article by Davies-Abbott and Roberts called for professionals to reduce labelling and to promote person-centred language in clinical documentation.

Language has the potential to cause harm. Trauma-informed dementia care requires services to recognise actions or interventions that may inadvertently damage wellbeing and to actively avoid re-traumatisation.

In light of the evidence outlined above, clinical psychologists of Psychology of Ageing Network (POAN), the Association of Clinical Psychologists-UK (ACP-UK) propose a shift in language from ‘behaviours that challenge’ to be managed, to ‘behavioural expressions of need’ to be met. This term appears in the British Psychological Society guidelines, ‘First-line psychosocial alternatives to psychotropic medication for Behaviours that Challenge in Dementia Care’. We believe that this change in language supports person-centred, trauma-informed, and intervention-based dementia care and can complement, rather than replace, medical diagnosis. We therefore invite all to consider changing their language to ‘Behavioural Expressions of Need’.

References

Bachelor, A., Rook, G., King, G., Dunn, L., Kennedy, S., Hayden, J., Davies, T. and Hare, P. (2023) How we talk about dementia: Good practice guidelines for language and images, KYN care home group, in partnership with Innovations in Dementia. Available at: kyn-lets-talk-about-dementia-guidelines.pdf [Accessed: 6 January 2026].

Davies-Abbott, I. and Roberts, E. (2025) ‘Reducing labelling and promoting person-centred language in dementia care case notes’, Journal of Dementia Care, 33(1), pp.31–35.

Hewat, E. (2025) ‘How we talk about dementia’, Journal of Dementia Care, 33(1), p.5.

James, I., Moniz-Cook, E., Duffy, F., Lord, N., Ritchie, M. and Reichelt, K. (2024) First line psychosocial alternatives to psychotropic medication for Behaviours that challenge in dementia care: A toolkit for health and social care practitioners. The British Psychological Society.
James, I., Reichelt, K., Duffy, F. and Moniz-Cook, E. (2021) ‘Getting our ‘Terminology’ Right: The Power of Language’, Journal of Dementia Care, 29(2), pp.24–27.

Jenks, K., Marshall, D. and Stokes, G. (2024) ‘Reducing psychoactive medication use: Find the ‘why’’, Journal of Dementia Care, 32(5), pp.34–39.

Kitwood, T. (1997) Dementia Reconsidered: The Person Comes First. Maidenhead: Open University Press.

Marshall, J. and Thwaites, T. (2024) ‘Non-pharmacological prescribing in a Care Home Liaison service’, Journal of Dementia Care, 32(5), pp.30-34.

Maslow, A. (1943) ‘Theory of Human Motivation’. Psychological Review, 50, 370-396.

National Institute for Health and Care Excellence (NICE) (2018) Dementia: Assessment, management and support for people living with dementia and their carers nice guideline [ng97] Available from: https://www.nice.org.uk/guidance/ng97 [Accessed: 6 January 2026].

Wolverson, E., Birtles, H., Moniz-Cook, E., James, I., Brooker, D. and Duffy, F. (2019) ‘Naming and Framing the Behavioural and Psychological Symptoms of Dementia (BPSD) Paradigm: Professional Stakeholder Perspectives’, OBM Geriatrics, 3(4), pp.1–25. https://doi.org/10.21926/obm.geriatr.1904080.

Wolverson, E., Dunn, R., Moniz-Cook, E., Grove, D. and Diaz-Ponce, A. (2021) ‘The Language of behaviour changes in dementia: A mixed methods survey exploring the perspectives of people with dementia’, Journal of Advanced Nursing, 77, pp.1992-2001.

Wolverson, E., Dunn, R., Moniz-Cook, E. and Dunning, R. (2022) ‘What do family carers think of the language used to describe changes in behaviour in dementia?’, Age and Ageing, 51, pp.1-8.