What use is theory to supporting people with challenging behaviours?

In a special issue of the International Journal of Positive Behavioural Support at the end of 2013, my co-authors and I took perhaps the unusual step of beginning a debate on the question of "What is Positive Behaviour Support?" by presenting a model/framework outlining what we know about why challenging behaviours occur in people with intellectual and developmental disabilities.

Whether or not you agree with everything that we weave together into our model, and putting aside the fact that for many dimensions discussed it would be nice to have better quality supporting research evidence, I believe that the world of PBS must start with an understanding such as the model we describe. The reason for this is that it is hard to understand what you need to do (what PBS is, and how you deliver this) unless you understand WHY you are doing it. The WHY is all about a conceptual understanding or an underlying theoretical model. Perhaps what is different about our approach is that the theory and why questions are not focused on the theory OF PBS, but rather a conceptualisation of the "problem" that PBS is designed to address.

The model paper that I am talking about is:


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.

Information about the journal can be found here:
http://www.bild.org.uk/our-services/journals/ijpbs/

Many services in the UK will have received a free copy of the IJPBS special issue on defining PBS so you should be able to access this paper. If you cannot, please email me directly: R.Hastings@warwick.ac.uk


Why should services and practitioners give a monkeys about theory?

The answer to this question is implicit in my introduction above - that to fully understand PBS, you need to understand what we know about why challenging behaviours occur. Once practitioners have grasped the underlying conceptual model, there are some profound implications. One is that so much of the underlying theory (and the practice related directly to the theory too of course) is rooted in Behavioural Psychology. Thus, you cannot have PBS without Applied Behaviour Analysis. PBS IS ABA in many ways, and its roots are in behaviour analysis. A second implication is for those hard-line ABA folks who suggest that PBS is NOT good ABA. Once you look at the interlinking/related factors that might lead to the emergence and maintenance of challenging behaviour (see our "model"), it is clear we are dealing with a complex system. ABA folks have key skills and key roles to play, but their competencies do not cover by any means all of the relevant dimensions.

This point about behavioural theory can also be extended to other theoretical ideas. Once you see the complexity of the system surrounding challenging behaviour in a clear model, it gives people a lens through which to assess the latest fads and ideas. Anyone suggesting a new all-encompassing theory that changes the way services ought to be organised around challenging behaviour is unlikely to be able to capture all of this complexity. In our review paper, we use the example of trauma-focused care. Of course, sensible people are suggesting we should look at trauma-focused models and see what they have to offer developments in PBS and those sensible people do not suggest we throw out everything else. If anyone was suggesting this though, the lens of the conceptual model shows us why this would be an unhelpful position. Some challenging behaviour, not all, might be associated with traumatic events. Some carers, not all, might experience trauma-like reactions to being exposed to serious challenging behaviours. See how the lens works?

We are also used to hearing that to work effectively to support people with intellectual disabilities whose behaviour challenges, we need a multi-disciplinary approach. I'm fed up with hearing this point being used to justify unco-ordinated teams of people doing their little pieces in the life of the person whose behaviour challenges. Defending professional groupings seems to be the priority. However, what these debates suffer from at present is the lack of a Unified Conceptual Framework. If everyone could sign up to a framework such as the one we describe, this would also help to clarify what competencies (not professionals, note) are needed within a team to work together effectively to provide support to those whose behaviour challenges and their families and carers.

How can services use the Hastings et al. conceptual framework?

It is important to start by saying that the conceptual framework we described in our paper is intended as a way to open and inform the debate, not necessarily as a fully comprehensive unchallengeable theory. That would be ridiculous. We do think, however, that we ain't done a bad job of pulling together sometimes unconnected areas of research and practice. Feedback so far supports that position, of course often with various qualifications.

Several times recently though, I have been asked what it might all mean for how PBS services should be designed. I have also been asked what we might need to do to train everybody within intellectual disability services in a way that will ensure better support to those whose behaviour may challenge. My answer is to start with a clear, agreed, conceptual model like ours.

As I'm only a humble researcher, I have restricted my responses then in the following ways. I hope that these thoughts may be useful:

1. Service level organisation. In terms of overall aspects of a quality service, and one that may stand a chance of reducing the likelihood of challenging behaviours emerging, I think the conceptual model gives a good idea of what we need to do. For example, better screening, identification and treatment for physical health conditions is important in a good quality intellectual disability service. It will also contribute to some reduction of the risks of challenging behaviours emerging. Improving friendship networks and general social support is important anyway for quality of life. It will also contribute to some reduction of the risks of challenging behaviours emerging. I won't go through every aspect of the model - I think you get the point. Much of this is not new in terms of what makes a good intellectual disability service. However, the specifics of linking this to attempts to reduce the risk that challenging behaviours may emerge perhaps is more novel. 
2. Assessment and Intervention for Challenging Behaviour. When it comes to then how best to support a person who has already developed behaviours that challenge, I come back again to the conceptual model. For me, it guides what should be a part of a fully comprehensive assessment that then directly informs a multi-element Behaviour Support Plan (BSP).
3. Competencies and Training. If we are thinking about services especially with paid support staff, then this two-level thinking I suggest gives us the building blocks for the design of training relating to challenging behaviour. A broad range of competencies (unlikely to be available via a single professional) is needed to carry out a comprehensive assessment and to design, deliver, and monitor a high quality (and likely more effective) BSP. Training needs to target all of the core competencies and an idea of how to effectively access the rest (e.g., by partnership with other professionals, the person with intellectual disability and/or their family). If we're thinking about what training ALL intellectual disability staff should engage with  under the "challenging behaviour" topic (e.g., the basic induction training), I wonder if the answer may be somewhat different to what many services do currently. So, it seems sensible that we will need to explain what we mean by "challenging behaviour" and greater emphasis probably needs to be placed on the fact that challenging behaviours are defined socially. However, what next? You may be surprised that I would suggest perhaps NOT to explain the behavioural model underlying much of our understanding of challenging behaviour. Instead, what are the key points in the conceptual model that if you could influence across a service would make the largest difference? The answer to this question requires some thought and actually some research, but how about: (a) some coping skills for staff to deal with their emotional responses when challenging behaviours do occur, and (b) some way to increase their empathy with the life situation of people with intellectual disabilities?

Please do extend this debate by leaving comments on this blog