What is Positive Behavioural Support?
Over the last three decades, Positive Behavioural Support (PBS) has increasingly become the model of choice in supporting people whose behaviour poses challenges to services.
While there are a number of existing descriptions of PBS available, a recent definition by Gore et al, sought to bring together the fundamental elements of PBS in a way that could usefully inform future service, policy and research developments. The key features of this definition are summarised below.
Gore and colleagues emphasise that PBS is a multi component framework for developing an understanding of behaviour that challenges rather than a single therapeutic approach, treatment or philosophy. It is based on the assessment of the broad social and physical context in which the behaviour occurs, and used to construct socially valid interventions which enhance quality of life outcomes for both the person themselves and their carers.
The framework consists of ten elements grouped into three overarching themes of values, theory/evidence base, and process. It is important to stress that these elements do not represent a ‘menu’ of options. Rather, the effective implementation of PBS necessitates the combined use of all of these elements.
Values PBS combines the technology of behavioural intervention with the values of normalisation, human rights, and self–determination to deliver effective person-centred support for people whose behaviour challenges. Crucially, these values inform both the way in which this technology is used and the outcomes that it is designed to achieve. PBS, therefore, aims to enhance quality of life as both an intervention and outcome for people who display behaviour that challenges and those who support them. PBS interventions are also constructional in that increasing the person’s repertoire of adaptive behaviours and their range of positive life opportunities is a central objective. In contrast, the use of aversive or punitive interventions is rejected on the basis of their incompatibility with a values-led approach.
Values
Prevention and reduction of challenging behaviour occurs within the context of increased quality of life, inclusion, participation, and the defence and support of valued social roles
Constructional approaches to intervention design build stakeholder skills and opportunities and reject aversive and restrictive practices
Stakeholder participation informs, implements and validates assessment and intervention practices
Theory and Evidence Base
An understanding that challenging behaviour develops to serve important functions for people
The primary use of constructional principles and procedures from behaviour analysis to assess and support behaviour change
The secondary use of other complementary, evidence-based approaches to support behaviour change at multiple levels of a system
Process
A data-driven approach to decision making at every stage
Functional assessment to inform function-based intervention
Multi component interventions to change behaviour (proactively) and manage behaviour (re-actively)
Implementation support, monitoring and evaluation of interventions over the long term
PBS takes account of the behaviour and well being of stakeholders (such as paid and family carers) and emphasises stakeholder participation to ensure that assessments, interventions, and outcomes are meaningful. PBS is therefore ‘done with’ rather than ‘done to’ the person and those who support them.
Theory and Evidence Base PBS is founded upon an understanding that behaviours that challenge serve important functions for those who display them. They develop and are maintained within the context of a person’s abilities, needs (including their physical and mental health) and circumstances and, critically, the characteristics of the social and physical environment within which the behaviour occurs. These environments often contain or lack important features that are provocative of behavioural challenges, and the term ‘challenging environments’ has been used to stress that many of the causal factors behind such behaviours lie outside the person. This understanding, together with many of the assessment and intervention methods utilised in PBS, is grounded in constructional principles and procedures from behaviour analysis.
PBS is also an inclusive approach which incorporates additional evidence-based approaches that are supportive of its stated values and compatible with its overarching framework. Process PBS requires assessment and support arrangements to be personalised and grounded directly in information that has been gathered about the person (including their broader needs and abilities) and their environment.
The PBS process begins with a systematic assessment of when, where, how and why an individual displays behaviour that challenges, a process known as functional assessment or functional analysis. The primary outcomes of this process are
A clear description of the behaviours of concern (including classes or sequences of behaviour that occur together).
The identification of the events, times, and situations that predict when the behaviour will and will not occur across the person’s full range of typical daily routines.
Identification of the consequences that maintain the behaviour (that is, the purposes or functions that the behaviour appears to serve for the person)
The development of one or more summary statements or hypotheses that describe specific behaviours, the situations in which it occurs, and the consequences that may maintain it.
The collection of direct observational data that support the summary statements that have been developed.
Reflecting the fact that behaviours that challenge often have multiple causative factors, PBS intervention plans typically have multi components which are built on the findings of assessment and devised in partnership with key stakeholders. Proactive strategies that seek to reduce the likelihood of behaviours of concern occurring should form the majority of any plan. These will include interventions aimed at increasing stakeholder quality of life, ones that seek to alter the contexts in which challenging behaviours occur, and those which support the development of new skills that serve the same function as the behaviour or which enable the person to cope more effectively with situations that they find hard to manage.
A PBS plan will also describe an appropriate and ethical range of reactive strategies to guide responses to incidents of behaviour that are not preventable and which aim to minimise escalation and reduce the risk of harm to the person and others. These should form a minority component of any plan, but play a crucial role in terms of making people safe.
Finally, PBS plans provide guidance on how strategies will be implemented, by whom and by when. Data-based systems are required to monitor both the reliability of plan implementation and resulting changes in quality of life and behaviours that challenge.
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