Article first published in CareKnowledge/Learning Disability Today December 2015
Installing a positive behaviour support team across an organisation is a major undertaking, but can bring benefits to individuals with learning disabilities.
Following the Department of Health’s response to the Winterbourne View scandal in 2012 and its recommendation for a whole-organisation approach to positive behaviour support (PBS), there has been increased focus on clinical provision in-house. Care providers have a responsibility to provide in-house behaviour support and not rely exclusively upon NHS or state provision.
The ideology around the holistic approach of PBS and the science of applied behaviour analysis (ABA) has been the subject of debate for several years, and continues to tax organisations providing social care support to individuals with learning disabilities, autism and associated developmental disabilities.
A core ideal of PBS is that in order to achieve sustaining and long-term reduction in challenging behaviours and improvements in quality of life for individuals, long-term multi-component implementation of proactive and reactive strategies is required.
It is a major undertaking when an organisation commits to adopt PBS company-wide, and establishing an effective framework for PBS best-practice is critical for success.
To implement successfully, the emphasis should be on a range of proactive strategies such as:
• Person-centred intervention, achieved by educating staff teams around the factors specific to an individual’s diagnosis
• Modelling interactions between staff and service users by offering coaching in successful engagement and communication styles
• Looking at changes in the environment that may alleviate behaviours and creating behaviour support plans from a point of informed evidence.
This everyday PBS practice has recently been supported by the National Institute for Health and Care Excellence (NICE) (2015) and by the Positive Behavioural Support Coalition UK (2015), a national steering group funded by Mencap. This suggests that proactive strategies should ideally be established from an ‘informed evidence’ base, using baseline data gained from first-hand observation of the person displaying behaviours.
But in the absence of collaborative working between sector providers and NHS or local authority-run specialist clinical behavioural support services, pressure on oversubscribed state provision for behavioural support just can’t be met, due to the excessive amount of detailed and intensive work required within a person’s living environment and the long-term continued clinical nature of PBS through a person’s life.
Examples of our behavioural team working with staff teams: ‘John’
For example, John, a man with autism in his early 20s, has been supported by the PBS team for the past 18 months. He came to Regard from a secure NHS unit where he had been displaying severe self-injurious tendencies, so a comprehensive behavioural assessment was required.
This included first hand observations, interviews with staff and family and visits to his previous placement, which enabled us to identify his various ‘sensory’ and ‘attention’-based behaviours.
Such an assessment process is time-consuming. To gain a clear understanding we have to observe at different times of the day and week: it can take more than six hours to observe and record behaviours, with notes being recorded every 20 seconds.
Our observations of the interactions between John and others, such as his support workers, gave us good information to discuss with staff, including their own initial responses to him. We could evidence that behaviours can be over-exaggerated or recollected wrongly, and the staff team reacted positively to being involved in the process.
John is now regularly out in community without behaviours – shopping, having his hair cut and engaging in leisure pursuits.
Staff teams as ‘mini behaviourists’ the eyes and ears: ‘Emma’
Although the clinical team can observe and capture behaviours that may challenge by regularly visiting a person’s home, it is impossible to be there all the time. A key role for PBS team clinicians has therefore been to train in-house staff teams to record behaviours.
Historically, ABC forms have been used to record behaviours in the field, although until now little has been done with the information recorded in terms of analysing patterns.
In the case of Emma, a non-verbal young lady with learning disabilities, staff felt she was simply aggressive. She would quickly change from sitting quietly, to grabbing and pulling at staff and others, without any obvious reason.
Her support workers were coached in what to record about an incident and how to graph her behaviours, and their findings – discussed at team meetings – revealed she had particular difficultly around mealtimes and when staff changed shifts. By capturing information about who is in the room, the time of day and who integrates with Emma, we can communicate to better meet her needs.
Technology in capturing behaviours
Over the past two years a big advance in Regard’s PBS service has been the development of a computer-based recording system for capturing behaviours. The major benefit of this is that it replaces some of the opinion about why behaviours may occur with facts, such as graphs showing when behaviours are most frequently seen.
The graphs can be based on the time of day behaviour is seen, those present, what happens in response to a behaviour, what preceded it. Their main aim is to increase awareness around triggers and proactive approaches, and they are discussed at team meetings.
Additionally, graph reports can be shared with social workers, GPs, nurses, psychologists and other allied health professionals to track and show when a new positive strategy around behaviours has been successful. This facilitates proactive support for service users, and aids collaborative working with NHS colleagues and coaching Regard’s staff teams.
Regard aims to develop this further by providing tablets for each service to use, featuring quick categories for capturing behaviours.
In addition, when alternatives to medication are used at times of crisis to manage a person’s behaviours, Regard can accurately track rates of the behaviour decreasing and regularly feed this through to NHS colleagues.
Getting the PBS team right
An important part of developing any team within an organisation is getting the mix right. Within organisations providing care a major part of PBS work is building relationships with managers and staff teams, so excellent communications skills and accessibility are vital.
Equally important – as noted in NICE guidelines and the PBS Competency Framework – is that clinicians should have appropriate training in behaviour analysis.
Regard’s PBS team features a mix of clinical psychology and applied behaviour analysis Masters and post-graduate backgrounds.
Training the workforce in PBS
The aim of Regard and other care providers is for PBS to permeate the organisation. Our PBS team regularly attend ABA and PBS conferences and workshops to stay up-to-date with developments in the field. Staff teams are then updated at regular away-days, giving them the chance to reflect and learn about topics such as autism, learning disabilities, intensive interaction, challenging behaviour and total communication.
It is crucial to ensure there is consistency in the support approaches offered to each service user, so we strive to include families, local colleagues and others involved in the person’s life in the training too.
Creating an environment with a PBS focus
One of the great advantages of care providers employing in-house specialist teams is the connection and link to management in that organisation.
A behaviour specialist may identify the behaviours through observational recording, coach the staff, and provide a functional assessment specifying the behaviours, but if the environment of a person with challenging behaviours is at odds with their needs that would also pose a major issue.
So in an organisation fully committed to PBS, the clinical team would design an appropriate living or sleeping environment at a service before an individual with learning disabilities or autism is placed there, providing guidance and design around the person’s space which can result in significant major reductions for such complex behaviours as destruction to their own property or furniture.
For more information go to: www.regard.co.uk/service-type/positive-behaviour-support-services
Department of Health (2012). Transforming Care: A National Response to Winterbourne View Hospital. Department of Health review: Final Report. London: Department of Health.
National Institute for Health & Care and Excellence (2015). Challenging behaviour and learning disabilities: prevention and interventions for people with learning disabilities whose behaviour challenges. NICE Guideline. London: NICE.
Positive Behavioural Support Coalition UK (2015). A Competence Framework. Positive Behavioural Support Coalition UK. London.