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Agitated Behaviour Scale

(as modified by Toronto Rehab Institute)


The Agitated Behavior Scale (ABS) was designed to be used by allied health professionals to
assess agitation in patients who had sustained a TBI (Corrigan 1989). According to Levy et al.
(2005), despite the availability of the scale, agitation remains unmeasured by most who work
with the TBI population. The scale, which began as a 39-item scale, was reduced to 14 items,
with each item scored from 1 to 4 (i.e. from absent to present to an extreme degree). The scale
which was originally tested by nurses, occupational therapists, physiotherapists, and other
hospital staff was designed to be used by allied health professionals (Corrigan 1989). The total
score, which is considered the best overall measure of the degree of agitation, is calculated by
adding the ratings (from one to four) on each of the 14 items. The scale can also be divided
into three subscales. Disinhibition subscale includes items 1, 2, 3, 6, 7, 8, 9, and 10,
the Aggression subscale includes items 3, 4, 5 and 14, and the Lability subscale includes
items 11, 12, and 13 (Corrigan & Bogner 1994). Individual scores of 22 on the ABS indicate
high agitation; conversely scores of 21 indicate low agitation (Corrigan & Mysiw 1988).
Patient Name: _________________________

Tested by: _____________________

Todays Date: __________________________


Nursing Observation Period:
Day Shift
Evening Shift
Night Shift

Profession: ____________________
Allied Health Observation Period:
30 minute time period
Start: ________________
End: ________________

Complete each of the following items. Do not leave blanks.


Score each item using the following scale
1 = absent (behaviour not present)
2 = present to a slight degree (behaviour does not interfere/disrupt)
3 = present to a moderate degree (behaviour interferes/disrupts but can be redirected)
4 = present to an extreme degree (behaviour interferes/disrupts and cannot be redirected)
Score
1.
2.
3.
4.
5.
6.
7.
8.

Short attention span, easy distractibility, inability to concentrate.


Impulsive, impatient, low tolerance for pain or frustration.
Uncooperative, resistant to care, demanding.
Rocking, rubbing, moaning or other self-stimulating behaviour.
Pulling at tubes, restraints, etc.
Wandering from treatment areas.
Restlessness, pacing, excessive movement.
Repetitive behaviours, motor and/or verbal.
Disinhibition Subscale = Total of 1 - 8

3.
9.
10.

Enter score from item 3 above.


Violent and or threatening violence toward people or property.
Explosive and/or unpredictable anger
ABS - 1

Agitated Behaviour Scale


(as modified by Toronto Rehab Institute)
11.

Self-abusiveness, physical and/or verbal.


Aggression Subscale = Total of 3 & 9 - 11

12.
13.
14.

Rapid, loud or excessive talking.


Sudden changes of mood.
Easily initiated or excessive crying and/or laughter
Lability Subscale = Total of items 12 - 14
Disinhibition + Aggression + Lability = Sub-Total
MINUS score from Item 3 above
TOTAL SCORE

Enter the Total Score and the Adjusted Score for each subscale into the row matching
behaviour severity.

Behaviour
Severity

Total score

Disinhibition
Adjusted Score

Aggression
Adjusted Score

Lability
Adjusted Score

21 or less
Normal
22 to 28
Mild
29 to 35
Moderate
35 or more
Severe

Adjusted Scores for Each Subscale


Disinhibition Subscale

Aggression Subscale

Lability Subscale

Total
Score

Adjusted
Score

Total
Score

Adjusted
Score

Total
Score

Adjusted
Score

8
9
10
11
12
13
14
15
16
17
18
19
20

14.00
15.75
17.50
19.25
21.00
22.75
24.50
26.25
28.00
29.75
31.50
33.25
35.00

4
5
6
7
8
9
10
11
12
13
14
15
16

14.00
17.50
21.00
24.50
28.00
31.50
35.00
38.50
42.00
45.50
49.00
52.50
56.00

3
4
5
6
7
8
9
10
11
12

14
18.67
23.33
28.00
32.67
37.33
42.00
46.67
51.33
56.00

ABS - 2

Agitated Behaviour Scale


(as modified by Toronto Rehab Institute)
21
22
23
24
25
26
27
28
29
30
31
32

36.75
38.50
40.25
42.00
43.75
45.50
47.25
49.00
50.75
52.50
54.25
56.00

ABS - 3