Sussex Partnership NHS
NHS Trust
Positive Behavioural Support for
People with Learning Disabilities who
present Challenging Behaviour
Dr Peter Baker
Consultant Clinical Psychologist/Honorary Senior
Lecturer
Sussex Partnership NHS Trust / Tizard Centre
University of Kent
Why focus on challenging
behaviour?
financial cost
Need and capability in services for
people with Intellectual Disabilities
CAPABILITY OF SERVICE TO RESPOND
INDIVIDUAL DEMAND ON SERVICE
RANGE OF SERVICE PROVISION
Creating capable environments
CAPABILITY OF SERVICE TO RESPOND
INDIVIDUAL DEMAND ON SERVICE
RANGE OF SERVICE PROVISION
Why focus on challenging
behaviour?
financial cost
31% of all people with learning disabilities
placed out of area (DOH 2004)
Why focus on challenging
behaviour?
financial cost
human cost
abuse
inappropriate treatment
psychotropic medication
restraints/protective devices
degrading abusive psychological treatments
exclusion, deprivation & neglect
challenges the comprehensiveness of
community care
Positive Behavioural Support for
People with Learning Disabilities who
present Challenging Behaviour
Traditional Behavioural Approaches
Positive Behavioural Support
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Influences
Definition
Characteristics
Evidence Base
Barriers to implementation
Early Behavioural Model
Behaviour
Early treatment strategies
Differential reinforcement schedules:
reinforcement of other behaviours or low
rate of behaviour.
Extinction: non-presentation of a
reinforcer.
Punishment:
type I application of an aversive stimulus
type II removal of a positive stimulus
Punishment based
strategies
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Time out (Mace et al., 1986)
Visual screening (Lutzker, 1978)
Verbal reprimand (Schutz et al., 1978)
Response satiation (Realon &Konarski, 1993)
Overcorrection (Foxx & Azrin, 1973)
Response interruption & manual restraint (Azrin et al., 1988)
Required relaxation (Foxx & Bechtel, 1983)
Mechanical restraint & protective clothing (Dorsey et al, 1982)
Water mist (Dorsey et al., 1980)
Aromatic ammonia (Tanner & Zeiler, 1975)
Electric shock (Linscheid et al. 1990)
Aversive tastes (Hogg, 1982).
Positive Behavioural Support
Human Rights Agenda
Deinstitutionalisation
Functional Assessment
Functional Assessment
Antecedents
Behaviour
Consequences
Functional Assessment
Challenging Behaviour
Functional Assessment
Environmental Factors
Lack of choice
Inadequate teaching strategies
Minimal access to engaging materials
Poorly selected daily routines
etc
Challenging Behaviour
Functional Assessment
Environmental Factors
Lack of choice
Inadequate teaching strategies
Minimal access to engaging materials
Poorly selected daily routines
etc
Individual Factors
Behaviour repertoire deficits
-Communication skills
-Self-management skills
-Social skills
-Self-help skills
Physical health
Mental heath
Challenging Behaviour
Positive Behavioural
Support
 ‘…characterised by educational, proactive, and
respectful interventions that involve teaching alternative
skills to problem behaviours and changing problematic
environments. It blends best practices in behavioural
technology, educational methods, and ecological
systems change with person-centered values in order to
achieve outcomes that are meaningful to the individual
and to his or her family’
Bambara et al (2004)
Positive Behavioural
Support
Is values led (in that the goal of
behavioural strategies is to achieve
community presence, enhanced choice,
improved personal competence, greater
respect and community participation,
rather than simply behavioural change in
isolation)
Positive Behavioural
Support
Is based on understanding of why, when
and how behaviours happen and what
purposes they serve (via the use of
functional assessment)
Positive Behavioural
Support
Focuses on altering triggers for behaviour
(in order to reduce the likelihood of the
behaviour occurring)
Stimulus based interventions
Interspersal training
Expansion of choice
Curricular modification
Manipulation of setting events
Positive Behavioural
Support
Uses skill teaching as a central
intervention (as deficiencies in adaptive
skills are often key contributing factors in
behavioural challenges)
Reinforcement based interventions
Functional Communication Training
Self Management
Positive Behavioural
Support
Uses changes in quality of life as both an
intervention and outcome measure
Positive Behavioural
Support
Has a long-term focus (in that challenging
behaviours are often of a long-term nature
and successful interventions need to be
maintained over prolonged periods)
Positive Behavioural
Support
Has a multi-component focus (reflecting
that the fact that challenging behaviours
are often multiply determined and also
that users typically display multiple forms)
Positive Behavioural
Support
Reduces or eliminates the use of
punishment approaches)
Positive Behavioural
Support
Includes both proactive strategies for
changing behaviour and reactive
strategies for managing behaviour when it
occurs (because even the most effective
change strategies may not completely
eliminate risk behaviours from behavioural
repertoires)
Allen et al. (2005)
The Time-Intensity Model of Aggressive Incidents
The physiological, emotional & physical path
Reactive
Management
Early
Intervention
Post-crisis
Intervention
Prevention
Baseline
Trigger
Escalation
Crisis
Kaplan & Wheeler (1983)
Remorse &
Recovery
Baseline
Positive Behavioural
Support
At the present time, PBS approaches
would therefore appear to offer the most
ethically stringent, evidence-based
intervention option for people with learning
disabilities and challenging needs. As
such, PBS may be said to represent a
socially valid intervention approach.
Allen et al. (2005)
Positive Behavioural
Support
UK research shows that only 2-20% of
people in need of such interventions
actually receive any kind of behavioural
support
Oliver et al, 1987; Harris & Russell, 1987; Qureshi, 1994
50-60% of people with learning disabilities
who challenge will be in receipt of
psychotropic (typically anti-psychotic)
medication
Kiernan et al, 1995; Fleming et al, 1996
Cochrane Review
‘It is debatable whether use of
antipsychotic medication for certain
people with a learning disability and
challenging behaviour is ethical outside of
a randomised control trial
Brylewski & Duggan, 1999
50% or more will be regularly restrained
Emerson (2002)
The Rhetoric Gap
What works best is used least and what
works least is used most
Possible Explanations
Lack of PBS trained staff
Cost
Prejudice
Useful Reading
Allen et al (2005) Positive Behavioural
Support: Definitions, Current Status and
Future Directions. Learning Disability
Review, 10,2,4-11.
Baker & Shepard (2005) The Rebranding
of behavioural Approaches for People with
Learning Disabilities & Challenging
Behaviour. Learning Disability Review,
10,2,12-15.