Thomas J. Willis

The efficacy of positive behavioural support with the most challenging behaviour: The evidence and its implications

Abstract Background Positive behaviour support (PBS) is behaviour analysis applied in support of people with challenging behaviour. Questions have been raised as to PBS effectiveness, costs, and accessibility. Method Outcome studies meeting specified criteria for PBS were selected for review. All told, 12 outcome studies encompassing 423 cases were included. Results This review showed that PBS was effective with both severe and high-rate behaviour problems, was cost-effective, used a methodology that was easily trained and widely disseminated, and worked in institutional settings in which the most difficult problems are thought to be, as well as in the community. Conclusions The major implication of this review is that practitioners may be obligated to use PBS when faced with the need to develop a plan of support given the ethical principle of using the least restrictive method consistent with the right to effective treatment.

A non-aversive rehabilitation approach for people with severe behavioural problems resulting from brain injury.

An approach is presented which uses exclusively non-aversive methods in the behavioural rehabilitation of people with severe behaviour problems resulting from acquired brain injury. The approach has five components: (1) behavioural assessment: analysing the way all aspects of a persons functioning may affect their behaviour, (2) positive programming: teaching the skills necessary to allow the person to achieve their desired ends without resorting to inappropriate behaviour, (3) ecological change: altering the environment to achieve a better match with the individuals cognitive deficits, (4) focused treatment: using behavioural contingencies to achieve a rapid reduction in target behaviour, and (5) reactive strategies: specifying action to be taken to gain short-term control over episodes of challenging behaviour. The current literature on behavioural rehabilitation is reviewed in the context of this approach. Two case studies are presented illustrating the use of the approach in practice. The strengths and potential pitfalls of the approach are discussed, along with issues which need to be considered for effective implementation.

A Positive Behavioural Support Model for Breaking the Barriers to Social and Community Inclusion

A key objective of the community care movement has been to achieve greater opportunities for people with learning disabilities to integrate and interact within their normal communities. Major barriers remain, however, for those individuals who are disabled and who also exhibit significant challenging behaviour. In addition to the unacceptability of the behaviours themselves, the support strategies used to remediate these challenges have also acted as a barrier to inclusion, because of their social unacceptability. The paper presents a model for supporting people who challenge that addresses these concerns by providing an effective, socially valid intervention approach.

Episodic Severity: An Overlooked Dependent Variable in the Application of Behavior Analysis to Challenging Behavior.

Although applied behavior analysis has made a significant contribution in the area of challenging behavior, to date, researchers have not systematically investigated the episodic severity of behavior as a dependent variable. Episodic severity is defined as the measure of intensity or gravity of a behavioral incident. Research up to now has investigated changes in behavior over time, but not the degree to or speed with which a behavioral incident can be safely resolved. As a result, practitioners have had to look beyond applied behavior analysis to emergency management systems such as Mandt, Nappi, CPI, and the like, which have not been empirically tested. This article proposes including episodic severity as an additional dependent variable to enhance the social validity of behavioral plans and discusses the resulting implications for new terms and strategies.

The safe management of physical aggression using multi-element positive practices in community settings

Background:Behavioral strategies often are used with people with acquired brain injury. Most involve the application of contingent reinforcement and punishment for selected behaviors or teaching important skills to overcome the challenging behaviors. However, consequential intervention and other strategies that depend on new learning may be precluded when working with individuals with significant short-term memory impairment. Main Outcome Measures:The present case study reports the results of non-consequential strategies based on a positive, multi-element model to address physical aggression and other related problems for such an individual. Results:Support did not involve the use of aversive consequences for challenging behaviors nor the use of physical management/restraint. The identified problems were effectively and safely addressed and community living in close proximity to his family was maintained. Conclusions:The implications of this approach for the support of people who face similar challenges are discussed, including the ability to address serious problems such as physical aggression without resorting to aversive procedures.

Developing behavioural services to meet defined standards within a national system of specialist education services

In response to increasing demand for more accountability and improved outcomes in the provision of behavioural services, Specialist Education Services (SES) in New Zealand employed the trainer of trainers programme developed by the Institute for Applied Behaviour Analysis (IABA). The goal was to develop a national training team capable of training SES staff to carry out assessments and develop support plans that could meet defined standards. The purpose of this study was to evaluate the outcomes of this trainer of trainers project. The primary methods of evaluation included the pre–post training comparisons of trainees’ functional assessments and positive behaviour support plans, against 140 defined criteria. The results of this project indicated that the SES national training team was able to train SES staff to meet the same standards of service delivery as the external IABA trainers. Further, a Periodic Service Review (PSR) system was implemented to insure that service standards could be maintained at a high level. A major conclusion reached in this study was that a trainer of trainer approach appears to be effective in preparing large numbers of educational personnel to meet the increasing demands by schools for professionals to meet a high standard of service delivery.

Special series on positive behaviour support--efficacy: research agenda.

In the following paragraphs, we outline a research agenda for positive behaviour support (PBS) that we inferred from the literature review and research studies reported in this special series of papers. Given that context, we are addressing a PBS research agenda for supporting people with the most challenging behaviour, not PBS in general. This proposed agenda is organised around major topics. Rather than suggesting that this agenda be adopted per se, our intent is to suggest some starting points that we hope will spark a variety of studies by our colleagues in the fi eld.

Special series on positive behaviour support—Efficacy: Introduction

E-mail: glavigna@iaba.com The special series of papers included in this issue of the Journal of Intellectual & Developmental Disability (JIDD) addresses the topic of positive behavioural supports (PBS) and the empirical evidence for its effi cacy. In particular, it addresses the questions that have been raised, not only regarding its effi cacy, but also its cost-effectiveness and accessibi lity, particularly with reference to the most seriously challenging behaviour. JIDD is proud to provide a spotlight on this very important topic by publishing these papers. The fi rst article, by LaVigna and Willis, offers a literature review of the research that addresses one or more of the questions that have been raised in relation to PBS, that is, applied behaviour analysis (ABA), in support of people with the most challenging behaviour. This literature is rich and includes Type 3 case studies (allowing valid inferences), multiple baseline studies, and control group comparison studies. Perhaps one of the reasons so much of this research has been beneath many people ’ s radars is that it has been carried out across and published in many countries around the world. These include Australia, England, Ireland, New Zealand, Scotland, and the United States. All told, the authors established rigid criteria for inclusion in the review. Twelve studies met these rigorous criteria, reporting the effects of PBS in support of over 400 individuals with various diagnoses, in a variety of settings. The range of countries, diagnoses, functioning levels, and service settings included in this review adds to the robustness of the fi ndings; that is, that PBS is effective with both high-rate and low-rate (of the most serious) behaviours, including serious physical aggression and self-injury, and is cost-effective and accessible to those who need it, in both community and locked institutional settings. The second article in this special series of papers is authored by Nicola Crates and Matthew Spicer from Tasmania, Australia. It is a remarkable contribution because it powerfully illustrates how widely accessible PBS can be made for those who need it through programs that train trainers (i.e., train-thetrainer programs). Crates and Spicer are members of Tasmania ’ s statewide training team, assigned with the responsibility of training staff working in the fi eld of developmental disability to effectively support people with challenging behaviour and to improve their quality of life. They were trained to be PBS trainers by the Institute for Applied Behavior Analysis (IABA). As cited in the LaVigna and Willis literature review, previous research has been published showing that teams that were appropriately trained could train others to meet defi ned criteria in carrying out comprehensive functional assessments and in developing and implementing multi-element PBS plans. Crates and Spicer not only replicate these fi ndings in their present study, as measured by these same defi ned criteria, but also include objective client outcome data empirically demonstrating that participating clients benefi tted signifi cantly from those PBS plans. These benefi ts include not only a signifi cant reduction in the occurrence of challenging behaviour, but also a signifi cant reduction in the episodic severity of their behaviour, a new dependent variable in PBS. Accordingly, their study adds to the literature verifying the accessibility of PBS and its effi cacy in supporting people with the most challenging behaviour leading to quality-of-life improvements. In this study there are also new implications for cost-effectiveness. Over the Journal of Intellectual & Developmental Disability, September 2012; 37(3): 183–184