I’ve got out of the habit of writing blogs for sharing with the world (who’s interested anyway in what I have to say about anything?!), or perhaps wasn’t sure I had something to say for a while. Several recent discussions with colleagues though have prompted me to write this piece about legitimate questions and comments about Positive Behavioural Support (PBS), and my personal thoughts on answers to these questions and points. The questions raised/points bring together the different ways I have heard several individuals talk about these issues rather than one person’s words. If you read this and think “that’s me”, then any similarity to what one individual may have said in my hearing is purely coincidental.
What is this thing called PBS – no-one really knows what it is?
Before the end of 2013, it is possible in the UK intellectual disability community that we could have argued that there was no agreed perspective on the definition/conceptualisation of PBS. There were many sources internationally where definitions and concepts were available and these were clear, but many of these resources are inaccessible by being hidden away in published journals.
At the end of 2013, a co-operative group of challenging behaviour/PBS practitioners and academics wrote articles for a special issue of the BILD-published International Journal of Positive Behavioural Support [http://www.bild.org.uk/our-services/journals/ijpbs/]. These articles included theory and research evidence about why challenging behaviours may occur in people with intellectual disability, a detailed definition of PBS, a discussion of the systems/organisational supports needed around PBS to ensure effective implementation, and a discussion of how (based on the newly formulated definition) the competencies required of individuals in delivering high quality PBS might be further defined.
The combination of the theory paper (Hastings and colleagues, 2013) and the definition paper (Gore and colleagues, 2013) provides a crystal clear perspective on what PBS is. It is very clearly a framework for both understanding challenging behaviour, developing interventions based on a personalised understanding of an individual and their challenging behaviour, and improving the quality of life of people whose behaviour challenges and those around them. PBS is not a treatment or one single intervention. Instead, a range of evidence-based practices and focused interventions will be brought together within a PBS framework to design an individualised plan (based on a formulation/conceptualisation of the core difficulties faced) to both increase quality of life and reduce the negative impact of challenging behaviour.
The Gore and colleagues (2013) definition is also closely aligned to international definitions of PBS, but with certain nuances to ensure it is focused on the UK context and specifically relevant to professionals and services working with people with intellectual disabilities. However, these papers also require payment or access to the IJPBS journal online or in print version.
Since then, the core definition of PBS has been used to inform a whole range of PBS resources and published online, completely free, and under a Creative Commons license that means anyone can use and adapt them without risk of breaching copyright. A variety of stakeholders have worked with the PBS Academy to develop these resources. First, we produced a Competencies Framework covering what people need to know and demonstrate that they do to show that they are delivering PBS as intended. Second, we asked different stakeholders to tell us what they needed from PBS resources to help them in their lives or in their work. The groups we worked with were: parents and family carers, people with intellectual disability, direct care staff, service providers and service managers, clinical professionals, and commissioners and care managers.
There is no equivalent in the UK of expert-developed definitions of PBS, and then co-produced practical materials. These resources have been developed for the benefit of everyone and are all available via the PBS Academy website:
The PBS Academy website also includes a link to the BILD-produced video for people with intellectual disability explaining to them what PBS is all about. Again, this video is informed directly by the definition formulated by Gore and colleagues (2013).
My apologies for a long answer on this first point, but I think you can see that it is absolutely clear within the UK what PBS is. There are also resources for everyone that explain this, and these are freely available to anyone with an internet connection. As far as I can see, there is no alternative conceptualisation out there in the UK with this pedigree, comprehensiveness, and degree of co-production of practical materials and guidance. Therefore, there is no confusion. Individuals may dislike aspects of the definition or wish that certain components were not included, but this does not take away from the fact that the definition is clear. We do know what PBS is.
Why does PBS have to emphasise “behaviour” or “behavioural”?
The PBS Academy suggests the use of the word Behavioural when talking about PBS – that is what the B stands for. The reason for this is that the use of a behavioural theoretical understanding and associated behavioural assessment and intervention methods are one of the core parts of the definition and conceptualisation of PBS. In fact, this is one of the 10 core features of the definition of PBS from Gore and colleagues (2013). This thinking assumes that for many people with intellectual disability (not all), their challenging behaviour is caused by aspects of their environment (both social and physical). Thus, a theoretical perspective and methodology is needed to develop an understanding of these environmental features and to design appropriate interventions using evidence-based practices.
An alternative perspective is that it really does not matter what “PBS” is called – the most important thing is the clarification of the underlying theory and definition as defined comprehensively by Hastings and colleagues and Gore and colleagues. Although there is value in a precise label, and Positive Behavioural Support is preferred, we don’t need to fall out about a name. I do realise that “behavioural” and “behaviour” sound aversive to some people and have connotations that are unhelpful. To be clear, PBS is not only about behavioural methods (see below) and it certainly does not see only the “behaviour” and not the person. Please read the detail of what PBS is and how it is used in all of the PBS Academy resources on or webpage. Then you will see that these perceptions are not reality.
PBS is just about Psychology or Psychologists
It is true that Psychologists, in theory at least, ought to be the profession most likely to already have many of the competencies defined clearly in the PBS Academy’s PBS Competencies Framework. In addition, before looking at the detail of the Competencies, many psychologists think they are experts in PBS. However, a part of the rationale for developing the competencies and describing functional “levels” of competencies within the Competencies Framework was to be clear that PBS is absolutely not about one profession or another. People I know with demonstrated competencies in PBS include Speech and Language Therapists, Occupational Therapists, Social Workers, Nurses, and Yes some psychologists.
It is also clear from our theoretical description (Hastings and colleagues, 2013) that evidence-based interventions addressing a number of dimensions or aspects of the lives of people with intellectual disability are a part of the PBS framework. Gore and colleagues also clarified that one of the 10 defining features of PBS is the use of non-behavioural evidence-based interventions. Interventions targeting, for example, physical health, mental health, relationships between people, social skills, communication skills, and occupational skills will all be a part of PBS interventions. The point is that a multi-disciplinary understanding of challenging behaviour and multi-component intervention are needed if you want to deliver successful interventions for people with intellectual disability and challenging behaviour. What is needed is a shared theoretical framework to guide this multi-disciplinary effort. Everyone working in, and protecting, their silos and their own profession is not helping and not consistent with the evidence for why challenging behaviours occur.
So, if you think PBS is all about Psychology only then think again.
There is no evidence for PBS and it didn’t work for me/doesn’t work for everyone
As we have seen, PBS is a framework and not a specific intervention. However, it is made up of evidence-based practices and a range of evidence-based interventions targeting key causal variables and important outcomes for individuals’ quality of life. PBS itself is evidence-based in the sense that it draws on underlying theory and evidence about why challenging behaviours occur. Like other service models or comprehensive “packages” addressing multiple outcomes, it is hard to evaluate the over-arching thing called PBS. However, it is not impossible. For example, we can evaluate if people have better outcomes when referred to a specialist service that runs on the basis of a PBS model. Professor Angela Hassiotis from UCL has done this within the gold standard Randomised Controlled Trial (RCT) design.
We could also train people in PBS skills and develop their competencies, and see if this makes a difference to the outcomes for people with challenging behaviour (see RCT underway also by the Hassiotis team).
Following the second approach, we could develop the skills of unpaid carers including parents of children with challenging behaviour and see if this training leads to reduced challenging behaviour and improved quality of life for the child and family as has been done by Professor Durand and colleagues in a RCT in the USA.
The RCT studies mentioned above that have released results so far do show that “PBS” as a whole is effective – at least following the designs and research questions that these designs can answer. However, a challenge with all of these evaluation approaches is having evidence that PBS was being implemented with fidelity otherwise we cannot say whether PBS is effective itself. This was one reason for us developing the PBS Competencies Framework and the additional PBS Academy resources. These could be used to develop tools enabling the checking of PBS delivery to make sure it is consistent with the overall framework as we defined.
Thus, there are several ways that we can challenge the suggestion that PBS is not evidence-based. However, it is appropriate to ask this question and to keep asking it. We do need to develop clearer evidence. However, in terms of service delivery in the UK right now what alternatives for comprehensive models or frameworks are there? Anyone?
Comments such as the fact that an individual with intellectual disability or a family carer has “had” PBS and did not think that it worked, play a central role again in the definition and scope of PBS. Another of Gore and colleagues’ 10 defining features is the core role of stakeholder direct involvement and feedback on the methods and outcomes of PBS. Thus, if a person or their carer is not positive about the outcomes their supporting team should have taken this very seriously indeed. A further one of the Gore 10 is also the use of ongoing data collection to inform PBS intervention decisions. Thus, if it was clear from either the person themselves, a carer, or other data sources that outcomes (increased quality of life and/or reduced challenging behaviour) were not improving, this should lead to some reassessment and re-designing of the intervention until it was successful. A feature of PBS ought to be that we don’t give up on a person. Interventions that are not working should be replaced with others and their outcomes also monitored.
That said, no approach is going to have a 100% success rate. Examples of failure do not invalidate the approach unless the examples of failure outweigh the individual examples of success. In addition, it is tempting to ask individuals who feel that PBS has not worked for them whether PBS was actually implemented with fidelity. With the PBS Academy resources, it will hopefully be easier in future to answer that question.
Finally, I would agree that no one intervention will work for everyone with challenging behaviour. That is one of the reasons why PBS is a framework incorporating a variety of evidence-based practices and interventions. This means that PBS is individualised for each person. Of course, there will still be failures but at least PBS actively attempts to personalise supports and should be flexible to change the interventions being used when it is clear they are not working.
PBS is not the only intervention for supporting people with challenging behaviour
As we have seen above, PBS is a framework incorporating a range of evidence based practices and interventions addressing a variety of risk factors and outcomes. Thus, it is not an intervention to be compared with (for example) Cognitive Behaviour Therapy. PBS is broader and could incorporate a CBT intervention if one of the factors determining a person’s challenging behaviour was an underlying mental health problem. I suggested above that there may be no other comprehensive framework for intervention for challenging behaviour in the field of intellectual disability that is built upon a clear model/understanding of the multiplicity of reasons why challenging behaviours occur. If there is something that compares in this way, then please do let me know.
Challenging behaviour is being seen as a diagnosis for which PBS is the treatment
This one really does annoy me I have to say, and it is tempting simply to dismiss it but I won’t. No PBS practitioner should in any sense consider challenging behaviour as a diagnosis, and in fact no-one should. It is clear that the definition of challenging behaviour emphasises the challenge posed by the environment and that challenging behaviour is socially-defined in terms of its impact on the person or others. Thus, you cannot simply look at a presenting behaviour and say “Yes, this is challenging”. You have to instead consider what impact the behaviour is having. Challenging behaviour as a diagnosis is not a part of PBS.
I have already dealt with the point about PBS not being a single treatment or intervention. Thus, neither part of this statement is true and certainly is not what PBS is about.
That said, there may well be thinking in some quarters that reflects this statement. Some people may well consider challenging behaviour as a diagnosis and “PBS” as the treatment of choice. However, this problem is not uniquely a challenge for PBS but is a broader misconception emanating from the view of challenging behaviour as a diagnosis. The whole field needs to challenge such an assumption, and I am pleased to see that this diagnostic perspective is not found in recent UK policy documents.
Gore, N. J., McGill, P., Toogood, S., Allen, D., Hughes, J. C., Baker, P., Hastings, R. P., Noone, S. J., & Denne, L. (2013). Definition and scope of Positive Behavioural Support. International Journal of Positive Behavioural Support, 3 (2), 14-23.
Hastings, R. P., Allen, D., Baker, P., Gore, N. J., Hughes, J. C., McGill, P., Noone, S. J., & Toogood, S. (2013). A conceptual framework for understanding why challenging behaviours occur in people with developmental disabilities. International Journal of Positive Behavioural Support, 3 (2), 5-13.