Reviewing models for PBS

There is widespread discord amongst learning disability practitioners regarding what constitutes Positive Behaviour Support and what does not. Some of this disagreement is due to different interpretations on the language used and differing opinions on the application of Applied Behaviour Analysis as the underpinning science for Positive Behaviour Support.

We have been debating the finer points of this argument for some time so we began to conceptualise how existing models may be reviewed to capture this. Here we will aim to present a revision of these models that encompasses all approaches to behaviour support. This is presented as a continuum: from the functional to the responsive management. This is not to suggest that plans should be at one end or the other, or that you will be exclusively using any one area of the continuum. This continuum is a tool so as you can break down each element of your plans for behaviour support and identify where this fits on the continuum. Towards the end of this blog we offer an opinion on which parts of this continuum fall into the Positive Behaviour Support approach and which do not.

We hope this review of the models adds to the much needed discussions on this topic. We feel we are not presenting anything necessarily new here, just a reviewed perspective on the highly regarded previous work in this area.

Introduction

There are two main models for presenting Positive Behaviour Support Plans. The first is the Donnellan & LaVigna model (1988). This breaks down plans into Proactive and Reactive strategies. The reactive strategies are totally non-aversive and therefore would not detail crisis management approaches such as the use of physical restraint or PRN medication. They would include things like active listening, or diversion. The Proactive strategies are largely focussed on getting support right when there is no challenging behaviour, promoting functionally alternative behaviours, and making a smooth fit between the plans and real life situations. These strategies are broken down into Ecological strategies (creating enabling environments, and changing the antecedent and setting events for behaviours), Positive Programming strategies (evidence based methods for teaching new skills), and Focussed strategies (ensuring that the behaviours that are being promoted have effective planned reinforcement schedules).

The second (See Allen et al, 2008 for examples of this)  is split into Primary Prevention, Secondary Prevention, and Reactive strategies. This reflects other models for preventative healthcare used in other areas. Primary Prevention includes the avoidance of antecedent and setting events and may include promoting functionally alternative skills to the challenging behaviour. Secondary Prevention strategies are how to respond to early warning signs that challenging behaviours are imminent. Reactive strategies are how to respond in situations of a crisis and may include both non aversive strategies and crisis management strategies such as restraint and PRN medication.

Both of these models have made significant contributions to understanding challenging behaviour and taking Positive Behaviour Support forward. However, these models do describe different viewpoints on approaches to behaviour support where there are gaps and overlaps between the two models. Here we suggest a review that conceptualises both models for describing behaviour support.

Assessment

Before describing the reviewed model it is worth noting the importance of assessment. A good behaviour support plan will be based upon an assessment. All behaviour assessments should include interviews with people who know the person and a review of previous instances of the behaviour to identify patterns. This should be included in any behaviour assessment.

Where this would differ in Positive Behaviour Support, and in fact any approach using Applied Behaviour Analysis, is that the assessment will have an increased focus on identifying the function of the behaviour rather than just describe and predict the behaviour itself. It will be looking for the functions the behaviour achieves for the person (what they gain or avoid as a result). In addition to interviews and reviewing recordings of previous incidents structured observations will be done to prove/disprove the reported information and to establish baseline data from which we can measure change. Without this functional assessment and baseline data we wont know what behaviours we need to increase. Without first identifying the function, plans can never be constructive by promoting more suitable independent behaviours. They will only be reductive trying to reduce behaviours that cause concern. If we consider that all behaviour is communicating something then by being reductive only we are taking away peoples voice.

The reviewed model

Building on the two models described above we recommend viewing behaviour support as a spectrum/continuum in four areas. The four areas will be briefly described here. As said in the introduction plans may always not have all of these elements, but will have at least one of these.  You should be able to review plans you have in place and identify which elements belong to which intervention category. We start with the most Positive Behaviour Support based elements – building functionally equivalent skills and end with the least Positive Behaviour Support elements – those that are purely reactive and aimed to stop a specific incident with no constructional elements.

1. Proactive Strategies

These are the strategies that aim to promote behaviours that achieve exactly the same function for the person as their behaviours of concern do. This may be making skills the person already has more effective or teaching the person new skills. It will look at the environment and make the environment more enabling for people, helping them to use their skills more effectively and making environments less disabling. It will look at the reinforcement needed to make the new/promoted behaviour more likely and permanently established in the persons repertoire, hopefully leading to further skill development in the future. It may include teaching coping strategies for recognised antecedents that lead to behaviours of concern.

2. Preventative strategies

This includes supporting people to avoid unnecessary antecedents to behaviours of concern. This may include designing environments to minimise challenging situations or to be safe during times of crisis, designing environments to reduce exposure to antecedent events, and providing high level access to reinforcements the behaviour achieves without needing behaviour or requests to get these.

3. Non Aversive Reactive Strategies

There are a variety of methods that can be used to bring incidents to a rapid end without causing distress to the person. Examples of these may include Strategic Capitulation, i.e. giving the person what they want, distraction/diversion strategies, and introducing competing contingencies where an alternative more reinforcing path is available. The key is that the person is not distressed by these approaches and would not have any concerns about them being used. Secondary prevention strategies may be included in here too which include responding quickly to early warning signs. This may include prompting the use of coping/self help strategies, talking with whispers, change of environment/person, or removing things that are causing concern.

4. Crisis Management

It needs to be acknowledged that sometimes challenging behaviour can be very dangerous causing severe damage to the person, their supports, property, or the public.  And sometimes the Non Aversive strategies will not be available or effective. In these situations crisis management strategies may be required. These may include the use of physical restraint or PRN medication. These approaches aim to contain the behaviour by restraining the person through holding them or using chemical sedation. Whilst these approaches are not person centred, constructive, and are not the preferred approach by anyone it is necessary to acknowledge they are used and can be an essential element of responsible care. With the use of the aforementioned strategies the aim should be that these strategies are only occasionally used and the previously described strategies should lead to a reduction in the use of crisis management approaches overtime. If only crisis management strategies are planned for then these are likely to be needed continuously.

Summary

The 4 stages of interventions described above can be used to evaluate what approaches are currently being used, or included in behaviour support plans. This reviewed model brings together two previously well recognised and highly regarded models for Positive Behaviour Support and brings these into a harmonious continuum.

This reviewed model also can be used to evaluate whether a plan is a PBS plan or just a behaviour support plan. The key element that will be seen in Positive Behaviour Support Plans opposed to behaviour support plans is the focus on promoting functionally alternative skills. You are also more likely to see establishment of baseline data and a functional assessment. The key elements that will be seen in a behaviour support plan opposed to a Positive Behaviour Support plan is the use of Crisis Management strategies and a focus on the challenging behaviour rather than an understanding of the function. Many plans will be developed that are somewhere between the two and it is hoped that presenting behaviour support in this way will support practices to move from behaviour management to a more Positive Behaviour Support orientated approach.

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