12 Steps To Effective PBS Plans

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My Cause

I believe in empowering others to live the life they want to live and I believe in making a positive contribution to my local community. I bring these beliefs to life by sharing information that will positively impact others.

I hold a BTEC Level 5 in Positive Behaviour Support and am currently studying for an MSc in Applied Behaviour Analysis, and I also run pbsaba.co.uk.

What Is PBS?

PBS is a framework for supporting people with learning disabilities and challenging behaviour to have a better quality of life. It promotes community life by combining the science of behaviour analysis with social role valorisation.

The History Of PBS

According to Dunlap et al. (2009), PBS started in the US around the 1980s. At this time, two things were happening: the civil rights movement and deinstitutionalisation. Behaviour modification was increasingly shown to be effective, but this included the use of aversive stimuli such as tabasco sauce and electric shock.

Aversive stimuli presented a moral dilemma as their use was socially unacceptable, yet they were supporting people out of aversive institutions. A socially acceptable technology was needed!

The Shift From Aversive Stimuli

The mid 1980s saw a shift in focus from just reducing behaviour of concern to also looking at why the behaviour was happening. Simultaneously, the development of functional analyses resulted in new ways of addressing behaviour of concern.

New research was also showing the side effects of aversive stimuli, for example, emotional outbursts and anxiety. With the need for socially acceptable interventions increasing, the US Department of Education provided funding for non-aversive behavioural strategies in 1987. Within a few years of that, Horner et al. (1990) coined the term Positive Behavioural Support.

Positive Behaviour Support Publications & Bodies

The UK’s Need For Behaviour Analysts

The prevalence rate of challenging behaviour in people with learning disabilities is 5 – 15% (NICE, 2015) and there are 1.3 million people with learning disabilities in the UK (Public Health England, 2023). That means there are approximately 65K – 250K people with learning disabilities who display behaviour that challenges.

According to the UK Society for Behaviour Analysis (2023), there were 533 registrants of the BACB in March 2023. That makes for more than 120 potential clients for every registered Behaviour Analyst in the UK.

The UK Evidence For PBS (Gore et al., 2022)

  1. In 2009, 63 individuals with learning disabilities and behaviour that challenges were randomly assigned to an NHS PBS team. The following was achieved:
    • Behaviour that challenges reduced for those that received PBS
    • The results maintained for 2 years
    • And there was no difference in cost to regular care.
  2. In 2011, a study of 285 cases showed that PBS resulted in significant reduction in behaviour that challenges.
  3. The implementation of setting wide PBS resulted in higher quality of care and reduced behaviour of concern in 2018.

The PBS Training Issue

Although PBS continues to grow in popularity, studies have shown that typical PBS training is of questionable effectiveness. This is because training did not always lead to positive outcomes for individuals.

The use of specialist PBS teams was shown to be more effective than the use of short training courses. Konstantinidou (2023) showed that challenging behaviour reduced in 90% of training cases reviewed, however.

PBS Qualifications

For each role, the qualifications below are recommended by The PBS Academy (2019):

Direct Care (Support Worker)

  • Foundation PBS training, 120 hours minimum e.g. BTEC Level 3 Advanced Certificate in PBS (310 hours)
  • On-the-job supervision & coaching
  • 1:1 supervision meetings at least once every 6 weeks.

PBS Supervisor or Manager

  • BTEC Level 5 Professional Diploma in PBS (equivalent to a foundation degree)
  • 52 hours supervision from more experienced practitioner
  • 1 hour clinical supervision every 8 weeks
  • 12 hours PBS CPD each year.

Higher Level Behaviour Specialist

  • PBS Qualification Level 6 (equivalent to a BSc (Hons))
  • 3 years of managing a PBS practice
  • 360 hours of PBS training
  • 1 hour of clinical supervision every 8 weeks
  • 12 hours PBS CPD each year.

Complex Case Behaviour Specialist

  • PBS Qualification Level 7 (equivalent to MSc)
  • 12 months supervision from a more experienced practitioner
  • 360 hours of PBS training
  • 1 hour clinical supervision every 8 weeks and
  • 12 hours PBS CPD each year.

How To Implement PBS

Step 1: What’s Important To Vs What’s Important For

  • Collaborate with the person and stakeholders to balance what’s important to, and what’s important for the person.
  • Use the Person Centred Planning evaluation matrix to check:
    • The level of family & friends involvement in support planning
    • How much the plan reflects what’s important to the person & the support required
    • And the extent to which the plan enables community access and inclusion.

Step 2: Defining The Challenging Behaviour & Risk Factors

  • Define the behaviour of concern, including the risk it poses, its impact on community access, as well as its frequency and duration etc.
  • Make note of the risk factors, for example, the severity of the person’s disability, any environmental mismatches in stimulation levels, or institutionalised practices.

Step 3: Before A Functional Assessment

  • Functional assessments are time-consuming, so before diving into them:
    • Check whether a person-centred plan been developed. This may reveal deficiencies that explain the behaviour of concern.
    • Check for evidence of a good quality of life. Again, major deficiencies may impact the person’s behaviour.
    • Check whether there are any undiagnosed or unresolved issues such as sleep problems, gastrointestinal disorders, constipation, allergies etc. All of these may impact on the person’s behaviour.

Step 4: Prioritising Behaviour

  • Tackling multiple behavioural issues simultaneously can become unmanageable. Follow these steps to work more efficiently:
    1. Meet stakeholders e.g. family, support workers etc.
    2. Work together to develop a list of behaviours to be targeted.
    3. Use the list to prioritise behaviours to be targeted by considering –
      • The risk the behaviour poses to the person and others
      • The impact on the person’s quality of life
      • And whether a high rate of physical intervention is being used as a result of the behaviour.

Step 5: Using Specific Tools

  • Use specific tools to ascertain the function of behaviour. These include:
    • Functional Assessment Interviews – a structured interview lasting approximately 90 mins, conducted with the person who knows the individual well.
    • Motivation Assessment Scale – a ratings questionnaire whose aim is to determine the function of the behaviour of concern.
    • Contextual Assessment Inventory – an assessment of setting events and discriminative stimuli for challenging behaviour.
    • Psychiatric Assessment Schedule for Adults With Developmental Disabilities – a mental health screening tool for adults with learning disabilities.
    • Mediator Analysis – an assessment of the strengths and needs of those who will be implementing the PBS plan.

Step 6: Data Triangulation, Formulation & Summary Statements

  • There is inherent weakness in the use of any one of these tools in isolation. To overcome this, combine the tools to see how well they support each other in the story they tell. This is called triangulation.
  • Combine multiple streams of data to develop a hypothesis. This is called formulation.
  • From this, develop a summary statement that details the risk factors, triggers and maintaining consequences for the behaviour of concern.

Step 7: Direct Observations

  • The tools in step 5 also suggest times when the target behaviour is most likely to occur, and therefore the best time to conduct observations.
  • Observations are important for:
    • Verifying your summary statements and
    • Providing a baseline of the target behaviour before any interventions are implemented.

Step 8: Mental Health

  • Consider mental health and whether challenging behaviour is an expression of an underlying issue.
  • Check whether input from a mental health professional is required.

Step 9: Social Validity

  • Consider whether the intervention is beneficial to the person and others.
  • The intervention must be acceptable and must be the least intrusive.

Step 10: Developing Strategies

Primary Strategies
  • These form the majority of the PBS plan.
  • They may include environmental changes such as:
    • Increasing the living space for someone whose challenging behaviour is more likely to occur in busy environments
    • Using active support for someone whose behaviour is more likely to occur during long periods without attention.
  • Primary strategies may include the modification of triggers through:
    • Removal or embedding of high-risk factors between low-risk factors
    • Increasing the person’s choice at potential flashpoints
    • Changing the sequence of events
    • Breaking down difficult tasks into smaller manageable steps
    • Using simpler instructions
    • Using graded support.
  • For behaviour of concern whose function is tangible, non-contingent reinforcement may be used. In this strategy, the desired item is made routinely available so the person no longer needs to engage in challenging behaviour to access it.
  • Satiation may also be used. In satiation, the desired item is delivered at such high rates that it loses its value. These rates are usually higher than in non-contingent reinforcement.
  • Another key intervention is teaching new skills. This may include:
  • Other primary strategies include the use of differential reinforcement to reward appropriate behaviour but not the inappropriate behaviour.
Secondary Strategies
  • These strategies are used once a person shows signs of early agitation.
  • They are designed to prevent a full blown phase of challenging behaviour.
  • The strategies include:
    • Identifying early warning signs of challenging behaviour and
    • Identifying strategies that will help, for example incompatible behaviours or coping skills
Reactive Strategies
  • You use reactive strategies when the behaviour inevitably takes place.
  • Reactive strategies are not “treatments”.
  • Reactive strategies focus on keeping the person and those around them safe. They may include:
    • Increasing personal space
    • Self-protective or breakaway procedures
    • As required medication with a clear protocol approved by a medical practitioner
    • Minimal restraint.
  • Gain consent from the person. Consent must be:

Step 12: Implementation & Maintenance

  • Before implementing the PBS Plan, check its quality. Do this by using:
    • A PBS Plan Checklist to ensure all essential elements are included
    • A Goodness of Fit test to check how well the plan fits the individual, environment and mediators
  • Train the mediators to implement the PBS plan with integrity by following these steps:
    1. Describe what the plan requires
    2. Demonstrate the requirement
    3. Get each mediator practise the requirement
    4. Give feedback on performance and repeat the steps until fluency is achieved.
  • Manage implementation of the plan using positive monitoring. These are regular observations carried out against a scored checklist that determines how closely interventions are implemented as intended.
  • Monitor effectiveness of the intervention by checking:
    • ABC charts
    • Incident records
    • Participation records
    • Frequency of reactive strategies
  • Troubleshoot when there is a lack of progress. This is usually because of one of 2 reasons:
    1. The plan is not technically sound, for example, the hypothesised functions may not agree with actual data
    2. The plan may be sound but its implementation is poor. Positive monitoring will help identify the problem. A poorly implemented plan may result in the development of:
      • Restrictive practices
      • Abusive practices
      • And reduced community access.
  • Carry out a Periodic Service Review. This is a collection of measurable statements about service standard goals that are specific, verifiable and objective. Examples of such goals include:
    • 100% of staff achieving 90% or more on positive monitoring forms
    • Team meetings taking place at least once per calendar month
    • Fire evacuations conducted once per week.
  • These are followed by management feedback and remedial action for improvement.

Conclusion

  1. PBS IS effective in reducing challenging behaviour and improving quality of life.
  2. Effective PBS requires multiple components.
  3. Are you looking to become a PBS Practitioner? Get The Quick Start Guide below!

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References

Dunlap, G., Sailor, W., Horner, R. H., & Sugai, G. (2009). Overview and History of Positive Behavior Support. Handbook of Positive Behavior Support, 3–16. https://doi.org/10.1007/978-0-387-09632-2_1


Gore, N. J., Sapiets, S. J., Denne, L. D., Hastings, R. P., Toogood, S., MacDonald, A., Baker, P. A., Allen, D., Apanasionok, M. M., Austin, D., Bowring, D., Bradshaw, J., Corbett, A., Cooper, V., Deveau, R., Hughes, J. C., Jones, E., Lynch, M., McGill, P., & Mullhall, M. (2022). Positive Behavioural Support in the UK: A State of the Nation Report. International Journal of Positive Behavioural Support, 12. https://kar.kent.ac.uk/93504/


Improving the quality of Positive Behavioural Support (PBS): The standards for training. (n.d.). Retrieved June 13, 2024, from http://pbsacademy.org.uk/wp-content/uploads/2017/10/PBS-Standards-for-Training-Oct-2017.pdf


NICE. (2015). Challenging behaviour and learning disabilities: prevention and interventions for people with learning disabilities whose behaviour challenges. In Nice.org.uk. https://www.nice.org.uk/guidance/ng11/resources/challenging-behaviour-and-learning-disabilities-prevention-and-interventions-for-people-with-learning-disabilities-whose-behaviour-challenges-1837266392005


PBS Academy. (2019). Improving the quality of Positive Behavioural Support (PBS): The standards for individual practitioners. In PBS Academy. http://pbsacademy.org.uk/wp-content/uploads/2019/04/PBS-Standards-for-Individual-Practitioners.pdf


UK Society for Behaviour Analysis. (2023). BEHAVIOUR ANALYSIS: FROM SCIENCE TO PROFESSION. https://uk-sba.org/wp-content/uploads/2023/03/STD-6-Science_09-Mar-23_published.pdf


Public Health England. (2023). Learning disabilities: applying All Our Health. GOV.UK. https://www.gov.uk/government/publications/learning-disability-applying-all-our-health/learning-disabilities-applying-all-our-health