A Masterclass in the Functional Assessment of Challenging Behaviour

A One-Day Event Tony Osgood

By using what we know, we can create better services... (EmersonMcGill & Mansell,1994).

It’s hard because it’s hard…

As if your life were not sufficiently busy you’ve either volunteered or been told to volunteer to attend an intense one day masterclass about functional assessment of challenging behaviour. A masterclass suggests you’ll have ancient secrets shared with you that will transform your practice, perhaps, even, your life. This of course is precisely what may not occur. But the day will be a chance to catch-up with some of the latest research-based practices that help identify why challenging behaviour happens – as assessment of the factors that predict and keep challenging behaviour worth doing.

John Clements said there’s nothing wrong with training other than it seldom works. It’s terribly reinforcing, regardless. For organisations, they can say they’ve provided training for staff. For the trainer, it is reinforcing because they get paid* and entertain a captive audience**. For staff it’s better than work. Training is only effective if it is enacted in practice. Therefore view today as information sharing and a space to talk.

Most participants welcome days that end on time, the content of which is relevant and interesting and well presented, and involves not only teaching but group work and opportunities for individuals to voice concerns or stories.

The content is aligned to the PBS Academy competency framework. We’ve included some key articles for you to read at your leisure, this workbook (for you to make notes), copies of the presentation slides, and some workaids – either as hard copies else in electronic form.

This workbook is intended to act as a series of prompts for you following the day. Go through this after the masterclass.

* I don’t** You wish

PBS is an approach that blends values about the rights of people with disabilities with a practical science about how learning and behaviour change occur. The overriding goal of PBS is to enhance quality of life for individuals and their support providers

Horner (1999)

Content …

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Positive Behaviour Support & Functional Assessment Methods Challenging behaviour, causes and influences Values (guiding principles) Positive behaviour support (best practice) Communication & quality of life Rapport & interactions

Data-Based Decisions Completing, coding and interpreting ABC records Direct observations (O’Neill’s Functional Assessment Observation Form & MTS) Questionnaires & Interviews Data in context: how data supports person-centred decisions (i.e. preferences,

activities and quality of life)How We Organise Interventions & Support Ideas

Reactive strategies (crisis management options [non-physical]) Fixing the environment Teaching new skills Quality of life interventions (choice, voice, active support) Supporting staff

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“Problem behaviours are often a source of confusion and frustration. The person engaging in problem behaviours may appear to find the behaviour difficult and painful. The families, teachers, support staff, and advocates of the person frequently are confused and distressed over the challenge of trying to alter such behaviour patterns. In many situations, problem behaviours may not only be dangerous but may also appear inexplicable. Such patterns of behaviour do not fit with the way we think the world should work and often don’t make sense to people in the throes of the dilemma created by their occurrence.

One of the goals of a good functional assessment is to bring clarity and understanding to otherwise chaotic and confusing situations. We seldom reach this goal by focusing on diagnostic labels, or the simple topography or form of the problem behaviour.

Given the need for a broad impact, behavioural support can often benefit from companion assessment procedures... person centred planning, activity assessment, and assessment of medical and physical issues.

It is through this broader process that we follow the advice of the noted behaviour analyst Dr. Todd Risley to begin good behavioural support by helping a person “get a life” and then build in the more detailed behaviour support systems that may be needed.”

- O’Neill, Horner, Albin, Sprague, Storey, & Newton, 1997Functional Assessment & Programme Development for Problem Behaviour

ResourcesThis workbook provides some resources and tools to help you understand why behaviour that challenges occurs. There are several resources accompanying this. But search online for positive behaviour support (PBS) or functional assessment and you’ll find a plethora of sites, links and advice. This day is not intended to be definitive, but a pragmatic introduction to supporting people whose behaviour challenges those around them. There are some key books that some of you might find useful, particularly if you’re keen to explore the topic in more detail.

One useful introduction to consider purchasing is an edited book by Steve Hardy & Theresa Joyce, published in 2011, called Challenging Behaviour and People with Learning Disabilities: a Handbook. A new edition is being written at the moment, edited by Dr Peter Baker and myself.

The other key book I’d recommend is called Communication-Based Interventions for Problem Behaviour: A User’s Guide for Producing Positive Change, by Ted Carr, Len Levin and others. Although published in 1994, it’s still an essential resource.

Dave Hingsburger’s books Behaviour Self and Do? Be? Do? should be compulsory reading for every parent and professional, as they are accessible, funny and provocatively person-centred.

On the web are many resources (check out http://www.dimagine.com), but two workbooks that guide you through comprehensive assessment and intervention options are

The Facilitator’s Guide can be found at http://apbs.org/files/PBSwhole.pdf

PBS: A Learning Resource can be found at http://www.nes.scot.nhs.uk/media/570730/pbs_interactive_final_nov_12.pdf

For further information about PBS and competency frameworks, seehttp://pbsacademy.org.uk

A final recommended book for anyone interested in working to deliver a well-organised service that is interesting and activity-filled, is Mansell, J., Beadle-Brown, J., (2012). Active Support: enabling and empowering people with intellectual disabilities, London: JKP

You will receive this handbook as well as blank copies of workaids and there are also some accompanying articles and presentation slides.

You can contact my through my website or via tonyosgood(a)protonmail.com.

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Challenging ‘challenging behaviour’

Challenging behaviour is a summary label for a myriad of behaviours that hurt or harm. We might find some or all of the behaviours set out below challenging, depending on where the person is, who person is, how often they happen, how intensely they occur, and our ability to understand why it happens:

Swearing Screaming Hitting others Kicking others Pulling hair Hurting themselves Eating or consuming harmful things Running away Withdrawing from activities Ignoring someone.

When we think about challenging behaviour in intellectual or developmental disabilities (IDD), we’re each likely thinking of different behaviours. Defining behaviour as challenging is usually a product of the behaviour’s impact. As such, challenging behaviours range widely in their topography (what they look like), as do the ecological, psychological and biological processes that underpin them.

One person’s self-injury may appear similar to another person’s, but the things maintaining the behaviours or triggering SIB may be completely different: you need to take an individual approach. One size fits no-one. One person may define ‘talking back’ or ‘interrupting’ a conversation as of little importance, even evidence of someone being self-assertive, but for another person this may be considered highly challenging.

So whilst challenging behaviour is real and impactful, different people think of it to mean different things. This is why we call it a social construction. A behaviour is defined as challenging because it is considered impactful due to

Where it happens How often it happens How intensely it happens How it reduces the people’s quality of life.

Who decides is also a factor. There is plenty of discussion that assumes challenging behaviour is part of a disorder or condition. The reality is it may not be so cut and dried. There are some conditions with associated specific behaviours, but these do not appear to be the most significant determinate as to why many people with IDD may display challenging behaviour at some point in their lives.

Challenging behaviour is only a barrier to inclusion and a good quality of life if there is poor support.

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It’s important to be as precise as possible when we speak of challenging behaviour because of the above. Saying someone is aggressive isn’t sufficient.

What causes challenging behaviour?

To begin, spend some time defining challenging behaviour.

Define five behaviours people think of as challenging

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Now are these behaviours limited to people with autism and/or learning disabilities?

Are these behaviours always challenging?

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Without sounding facetious, challenging behaviour is caused by the same factors that cause any other type of behaviour. Research suggests most challenging behaviour is learned in the same way we learn most other behaviours. Of course behaviour is influenced also by how we’re feeling – both physically and emotionally. Rarely genetics plays a part, too.

By this we mean challenging behaviour is effective in getting or avoiding something in the same way asking or doing does. The difference is this: typically non-intellectually disabled people have a range of ways of having their needs met. We learn to wait, to ask, to do things for ourselves. In people with IDD opportunities to learn new skills may be lacking, and the capacity to acquire or retain skills may be impacted.

Challenging behaviour will continue so long as the person can achieve the things in no other way.

Influences on challenging behaviour include Physical well-being Mental well-being Learning and experiences An interesting life with control and involvement in activities, friends and

places life is lived Communication skills Having alternative ways of getting needs met.

In the vast majority of cases our behaviour is influenced by a mixture of internal and external factors and is a learned response to the situations we find ourselves in. We learn to behave in certain ways in order to achieve things we feel we need to. Behaviour serves a function for the individual, however odd or inappropriate it seems to us.

There are a number of factors that are likely to contribute to people learning unusual and possibly challenging ways of achieving what they need to... none of which are exclusive to people with learning disabilities...

Social factors: poor care, rejection by society and individuals, such as carers or peers. Environments that are highly controlling, with high levels of tension are likely to engender behaviour problems. Individual learning histories are also important. A history of abuse & neglect can result in high rates of socially unusual behaviours. The reputation and status of the person can result in restrictive environments, maximise confrontations, being thought “essential” to “manage” the person, and environments that over-emphasise risk reduction.

Cognitive factors are important, such as problem solving skills, poor social skills, and communication deficits, degree of impairment, communication difficulties,

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Biological factors: organic brain ‘dysfunction’, epilepsy, hearing and visual difficulties, and certain “temperamental characteristics”, such as a high intensity of emotional responding and poor adaptability to new situations. “Behavioural phenotype” may influence some individuals.

Emotional factors are influential such as mental illness, or emotional well-being and coping skills.

Eric Emerson has defined challenging behaviour as ‘behaviourof such intensity, frequency or duration that the physical safety of the person or others is placed in serious jeopardy, or behaviour which is likely to seriously limit or deny access to the use of ordinary community facilities’ (Emerson, 2001, p. 3).

People whose behaviour others find challenging experience many consequences. It can lead to the person gaining a severe reputation. It can be mean lots of people become involved offering advice. It can limit opportunities. It can make people think the person’s challenging behaviour is an inherent part of them- they are challenging. It can lead to service providers making a lot of money. And it can reduce the quality of life experienced by the person and those around them.

Whereas we know that for most people associated with behaviours that challenge, those behaviours are learned. In effect, unusual or challenging behaviours are often about a lack of skills, a lack of communication partnerships, and a lack of support.

So think of challenging behaviour as indicating a learning issue. If a child doesn’t know how to read we try to teach the child to read, and the same goes for swimming, writing, speaking and making pannacotta. But if a child doesn’t know how to behave or communicate, we tend to blame the parents before making a referral to specialists.

So we consider challenging behaviour as in part a social construction. Challenging behaviour is most often learned.

And if challenging behaviours are currently happening, then science tells us something really profound: the challenging behaviour is being reinforced somehow, someplace.

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There are a number of influences that decide if challenging behaviour might appear, including skills, genetics, upbringing, mental wellbeing, and communication ability. There is also the thorny issue of environment.

Write down some influences for aggression- what ‘makes’ people aggressive?

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Now the important thing to consider is this: what if the influences upon socially approved behaviours (like buying chocolate biscuits for friends) are the same for socially unpopular behaviours?

What if the factors that influence you learning to drive, swim, enter Britain’s Got Talent, are very similar to those influencing challenging behaviours?

It might imply if there are things we can do to help people learn things, then we can alter challenging behaviour.

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Positive Behaviour Support

Positive Behaviour Support is based on behavioural psychology models: behaviour occurs for a reason. There are predictors to all behaviours, and consequences. Consequences can be gaining attention, gaining items, escaping or avoiding unpleasant situations or feelings, as well as gaining pleasant feelings both physical or emotional.

Natural events in our daily lives function as reinforcers and punishers for our behaviour. It is seldom acknowledged, however, that the momentary value of these events as reinforcers or punishers in continually in flux. The reinforcing value of food rises and falls depending on circadian cycles and when we ate our last meal… to date, behaviour analysts have been prone to describe behaviour (and build models of behaviour) with the assumption that the value of reinforcers and punishers is stable. A key feature in expanding our understanding of human behaviour is that the value of available consequences is forever increasing and decreasing…”

Horner, Vaughn, Day, Ard, 1996- ‘The relationship between setting events and problem behaviour’. In Positive Behavioural Support (Eds. Keogel, Keogel & Dunlap) Paul H.Brookes, Baltimore

“The PBS approach refers to those interventions that involve altering deficient environmental conditions… and/or deficient behaviour repertoires… increases in positive behaviour, lifestyle change and decreases in problem behaviour define the core of PBS…”(Carr et al., 1999)

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Positive Behaviour Support (PBS) is not a new approach to understanding and responding to challenging behaviour but a label applied to a variety of approaches with good empirical evidence. PBS balances values and science. One of the characteristics of PBS is inclusion of stakeholder views. The experiences and knowledge of families, people using services or requiring additional support, and direct carers, will remain tacit unless those facilitating PBS act to work in partnership.

A PBS environment is characterised by involvement not control, an active, interesting and meaningful life not having done things for people, rich tapestries of rapport & social engagement not islands of loneliness, choice not restriction. Challenging behaviour is to be understood, and alternatives taught, not a problem to be managed.

PBS practitioners aim to generalise the approach to family and service staff by embodying not only technical knowledge, but also person centred leadership. Decisions about how support is provided are based on data and a functional understanding of what results in challenging behaviour, as well as an understanding of what the person requires, needs and wants. PBS will use the least restrictive interventions, be minimally intrusive and maximally effective. It educates.

The key themes in PBS are: An understanding that evidence shows most challenging behaviour is

functional – meaning the person gains or avoids something from such behaviour. Challenging behaviour is effective in the absence of other ways of achieving these things. To reduce challenging behaviour it must be made less effective than more appropriate or less harmful behaviours. Therefore PBS builds alternative skills.

To alter the environment to make it better suited to supporting individuals in a way that teaches them new skills and gain more control. Therefore the goal of PBS is to improve quality of life.

To be effective, we work with in partnership with people to understand challenging behaviour, develop information, set goals and interventions, and evaluations.

Levels of PBS Skills: Three Tiers

Research shows that some 15-20%% of individuals with IDD will develop challenging behaviour, although the figure varies by study. We can think of children and adults with IDD as falling into three groups or tiers: those who do not present challenging behaviour (the vast majority), those at risk of doing so (often those with more profound needs or harmful experiences), and a minority of those who present complex behaviour.

We can conceptualise support systems as likewise falling into three groups. Direct carers/support workers who are able to provide proficient person-centred, active and meaningful support will require knowledge and support to enable them to

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support well the majority of children or adults with IDD (tier 1). Where children or adults are at risk of developing challenging behaviour – where needs are more pronounced - more specialist knowledge is required, for example detailed information about developing communication support plans, antecedent interventions, functional assessment and active support. The final tranche (the third ‘tier’) requires highly specialised knowledge and skills. These might include the ability to conduct functional analysis as well as more nuanced functional assessment work.

Staff will need to have differential levels of qualification or competence. Direct workers (support staff) will be skilled in good, person centred active support, enabling communication, and rapport.

This PBS training proposed might be conceived as tier 2. Tier two professionals with a variety of qualifications including functional assessment and practice leadership, skills teaching and person-centred practice will often be leading culture and support.

One account of the skills each tier requires can be found at the PBS Academy, here:http://pbsacademy.org.uk/wp-content/uploads/2016/11/Positive-Behavioural-Support-Competence-Framework-May-2015.pdf

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Principles Underpinning PBS

Behaviour is in the main learned; people engage in behaviours to "get" something or to "avoid" something. Every interaction you have with another teaches them and you something. Behaviour might be understood to usually ‘communicate’ need- it usually has meaning, however, do not assume others know your rules, expectations, or have equal social skills.

It is sometimes helpful to think of the four broad ‘reasons’ people do the things they do:

to gain attention (positive reinforcement) to escape or avoid things/people (negative reinforcement) to gain something tangible such as food, money or an activity (positive

reinforcement) to gain sensory or automatic reinforcement (makes you feel/sense

something) (positive reinforcement)

PBS describes what the specific function of a challenging behaviour is and bases intervention on this.

For example, if a person engages in challenging behaviour and gains escape through it, an intervention is designed to teach alternative ways of gaining escape whilst also teaching those supporting the person to make more appropriate requests.

To inform how we respond to challenging behaviour it is best to know why it happens. If we are not clear on the why, the how can go awry. To begin to explore why, three questions can be asked:

Is the person well, living an interesting and meaningful life, surrounded by people they like?

Is the person’s ability to communicate recognised and responded to? What events regularly predict and follow the challenging behaviour?

In the thirty years I have worked to support people to understand challenging behaviour there have been three major themes:

We now understand challenging behaviour is meaningful for the person. Before thinking about how to support someone, we need to understand what the behaviour achieves for the individual.

We now understand that behaviour can be thought of as communication. This helps us to see that teaching new ways of behaving and communicating is essential. A plan lacking strategies to aid communication is a poor plan.

We now know quality of life is an intervention in and of itself, not a future goal. A life without rapport, friendship, opportunities to make choices and learn, a life lacking activities to enjoy, is a poor life.

Waiting for challenging behaviour to disappear before increasing choice and opportunities means the person may never qualify for an ordinary life: they will live a

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life caught in a limbo between their severe reputation and a desirable future. Such decisions exacerbate challenging behaviour.

PBS grew out of dissatisfaction at what was custom-and-practice, namely, an over-reliance of aversive ways of dealing with challenging behaviour. Aversive approaches often dehumanised people, and included

restraining people through use of pain, using medication to dull people, threatening or scaring people, using isolation or taking away things that mattered.

Many interventions focussed on doing things following an incident – a little like designing a shoddy stable door long after the horse has bolted. It was very common for people whose behaviour challenges to be placed in ‘time-out’ – places or spaces where they weren’t given attention, or were isolated from the things they liked or needed. PBS demands people ask more about time-in than time-out. PBS asks us to consider how can we build skills rather than punish people.

When people ask me what PBS is, I suggest it is about catching people being good or doing well, and reinforcing what is helpful, not punishing what is not. If we paid more attention to people when they are not challenging, a lot of upset could be avoided. Even more can be avoided if we teach people to not need to challenge.

There are many definitions of PBS, but most include the following: An improvement in lifestyle (supporting the person to live a life they prefer); Use of functional assessment to identify why behaviour is happening; Use of many interventions that like a mosaic, when seen together, make a

picture of coherent support. PBS makes the place the person lives fit for them (we call these ecological changes), PBS tries to set things up to avoid conflicts (we call these antecedent interventions), PBS teaches new skills to people using and providing support, PBS enriches a person’s life with lots of activities, people and things the person enjoys, and PBS seeks to not use aversive or punishing strategies;

A long-term perspective: PBS wants to fix the future by fixing today; The voices of people using support are as important as others; PBS makes use of various approaches to help support people, for example

person-centred planning, psychological, nursing and other perspectives

PBS assumes there is contingency underpinning all behaviour. Setting Events (Motivators) alter the reinforcing potential the Antecedents (Predictors) signal about the consequences, thus affecting the likelihood of Behaviour.

For example, one day you ask someone to help with the washing up and they are rude and storm off. This is unusual because most of the time they seem happy to do the washing up. Careful discussion shows the individual is tired from a lack of sleep, has had non-preferred staff supporting them for two days – and these staff are not so good at communicating. The above are all setting events. So when you ask about

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the washing up, your request is an antecedent. The consequence of the person being rude and walking away is reinforcing because they escape your request. Thus they learn the following: when I’m tired and feeling ill, and so less tolerant, when you make a demand of me, being rude and just walking away means I escape you and your demand.

What support strategies might you use to amend this?

Think of support strategies that change or neutralise the setting events:

The antecedents:

The behaviour:

The consequences:

These strategies must all be based on the function of the behaviours – escape.

Once done, you’ve actually begun to describe a multi-element intervention.

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PBS then bases support strategies on why a behaviour happens, when it happens, with whom, and how intense or dangerous the impact of the behaviour is.

It works by teaching alternative skills to the person and those around them, improving quality of life, and fixing the ecology. It works in partnership with person-centred planning, and fits well with person-centred active support. We’ll explore more about PBS as the days progress, especially when we think about intervention strategies on days three and four.

We humans have evolved (learned) hundreds of ways of achieving these functions (some of which were useful thousands of years ago but not so helpful today- like xenophobic responses), and I want you to think of a behaviour that regularly helps you and a person you support to….

a) Gain attention

a. You –

b. Supported Person –

b) Escape things you don’t like

a. You –

b. Supported Person –

c) Getting things (tangible items)

a. You –

b. Supported Person –

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Communication & Quality of Life

Quality of LifeQuality of life is a subjective experience. What makes my life enjoyable and worthwhile is likely different from yours. There are a good many serviceable definitions of quality of life, but I think of it as people enjoying interesting active lives within equitable relationships in places they like.

We would do well to consider these five principles when creating support strategies: Do strategies enable the person to belong (to be present in a community)? Do strategies support the person to participate in the community? Do strategies offer opportunities to grow competence? Do strategies show how to respect the choices of people? Are we able to demonstrate our respect for the person, and ensure their

dignity? (O’Brien, 1987)

These five accomplishments can contribute to an adult’s quality of life.

Quality of life is the end product of service provision, but it is also the method of providing such a service. Any behaviour intervention that fails to consider quality of life is not fit for purpose in the context of PBS.

PBS uses clinically valid interventions (approaches with evidence to support them) but also socially valid methods (addressing a significant issue for the person in a manner that others would find acceptable). An intervention that reduces the rate of behaviours whilst leaving the person on dangerous levels of medication, not going out, or not busy in activities they choose or enjoy, is not PBS.

“We have historically been more effective in providing people for services than services for people... both family members and professionals can have more influence over than involvement in a person’s life.

This atmosphere of remote control casts people in a negative light. This focuses planning on people’s perceived deficits rather than their capacities, on what could go wrong rather than on what people need for things to go right.” John O’Brien & Herb Lovett, 1992

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To address quality of life, PBS is often complemented by person-centred planning (PCP). PCP, depending upon which method you employ, can explore and discover ways of supporting the person now, it can discover their history, and it can describe their preferred futures. PBS can contribute to the achievement of the goals set out by PCP.

CommunicationGeraint Ephraim suggested that behaviour was communication: “…there is no such thing as challenging behaviour. What we have is exotic communication… A punch in the face is an act of communication which is very difficult not to hear. Its effect may be heard but the message behind the punch may not have been listened to, let alone understood” (Ephraim, 1998, p.211/212).

Ephraim continued: “So far I have used the word communication as if it were a parcel that one person virtually throws at the other. If they’re not attending, the parcel will hit the receiver in the head and it will hurt. It hurts ‘cos they ain’t been listening. If they’re attending then they will catch the parcel and they won’t be hurt” (ibid, p.212). Ephraim suggested it is highly likely someone hit in the head by a parcel will become a little disorientated and might even throw a parcel or three back, thus qualifying as exotic communicators ourselves. Too many interactions end in the livid throwing back and forth of parcels. Instead of a conversation that is mutually respectful, we can end up in a struggle for control, and where such struggles dominate the narrative, we find exotic communication. Ephraim argued exotic communication is an expensive way to deliver not a very good life, and he recommended investing in mutually respectful conversations saves money and is more likely to contribute to everybody’s happiness. Ephraim shows the vital importance of taking people seriously as communicators worthy of being heard.

Exotic communication is a helpful motif because it is an easy way to comprehend the implications of the communication hypothesis. This argues challenging behaviour can be thought of as containing a message to us.

It doesn’t take much to foster exotic communication because it is hard to take people seriously when we believe we are better than them or that their voices don’t count because of a label. We can change what we do in light of what we think the behaviour is ‘saying’ but how we interpret the message of the behaviour is utterly dependent on us taking the person seriously enough to assume their behaviour can tell us something.

Communication is not merely speaking, writing or signing, but behaviour in its broadest sense. How we stand, how we refer to people, how we respond to them, are all modes of communication. Communication is the meaningful transmission of information from one to others by shared modes (or codes). This is why someone you know can communicate a lot to you with one look. Someone who doesn’t share that code will not succeed in receiving your message if they do not share your code.

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To fix communication we need to grow meaning between one another, not merely develop good expressive skills, and receptive abilities. Communication ecologies are the places in which communication take place: if the communication ecology is full of pollutants – too much noise, too much talking, not enough listening, too many strict views about what mode of communication is acceptable – communication will not be as successful as it might be.

Health & Well-Being are important elements of many people’s quality of life. Seeking to understand why behaviour happens and how to respond involves giving thought to the individual’s physical, emotional and mental wellness.

Question: thinking of the person you are working to support, how do you know if the person is experiencing health issues, sensory challenges or emotional health difficulties?

Notes:

Question: thinking of the person you are working to support, how do you know if the person is enjoying a particular activity? How was the activity chosen and prepared?

Notes:

Rapport, Interaction: Preferred Interaction Profiles

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There’s a great book by Kes Grey & Nick Sharratt. You’ll not find it catagorised under psychology or positive behaviour support but under children. Eat Your Peas tells the story of Daisy and her mother negotiating how to overcome Daisy’s aversion to peas. Mum wants Daisy to eat peas. Daisy doesn’t like peas. So mum takes a classic methodology to the task by manipulating contingencies of reinforcement... also known as Grandma’s Law: if you eat your peas you’ll get ice cream. Daisy’s mother soon learns that despite offering extra puddings, offering late nights, trips out, bicycles, chocolate factories, elephants and every goody on the planet (eventually), still Daisy doesn’t like peas. Despite the overwhelming power of mum, Daisy declines to eat peas; the more Daisy declines, the higher mum raises the stakes. It is Daisy who provides the solution when she then asks mum if mum would like to eat a vegetable of equal abhorrence. Mum says she doesn’t like vegetables. They overcome the confrontation by agreeing how they both like ice cream. Peas, it transpires, are not a big issue.

And that’s the difference between positive behaviour support and strict enforcement of applied behaviour analysis-informed intervention plans. PBS works in partnership with what we have. It focuses not so much on clinical validity as social validity, not so much on discrete trials than rapport. Not so much on reducing problem behaviours as increasing helpful behaviours.

If someone wants to know about positive behaviour support, sure they can go read the Journal of Positive Behaviour Interventions, they might even wish to buy the impressive Handbook of Positive Behaviour Support if they have a spare £150, or invest in the myriad of books on using minimally aversive support technologies, but they might be prompted to start by reading Eat Your Peas and being asked, ‘so, you get the point, right?’

It’s also the difference between support and support informed by rapport.

Rapport simply means we share common interests, we like one another, and we understand each other. As a result, people enjoy spending time together, and cut each other a break. To communicate effectively, we need to share a code; to communicate joyfully, we need rapport. If the person we are with is disinterested in us, it is unlikely they will hear us or heed us.

Poor rapport is a predictor of us not communicating, a signal for us to not share ourselves. To support cooperative interactions, the ebb-and-flow of give and take, it is helpful to have good rapport.

Rapport can take time to develop because we need to learn about each other: what the person enjoys is not always common knowledge. But if you want to invest your time in discovering the interests, preferences and personality of a person, you are likely to receive a not inconsiderable dividend: reciprocal rapport. You can spot two people with good rapport because they pay attention to one another- they notice what the other is doing. It takes only one person with good rapport to defuse quickly

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an escalating situation. Investing in rapport is akin to saving into an ‘emotional bank account’ (Covey, 2004): the more regularly you invest, you more credit you can call on. Perhaps this is why we speak of ‘paying attention’.

How on earth do you achieve rapport with an individual with IDD? Ephraim’s work is relevant here in that the first step is to take the person seriously. Then “associate yourself repeatedly with a wide variety of activities, people and things the person values, then eventually your presence will become a signal that many rewarding activities and events are available with you” (Carr, et al., 1994, p.112). You know when rapport is developing when both you and the person seem happy to spend time with one another.

Questions Do you know the person’s preferred items or activities? Are these provided abundantly and for free? Do you share interests?

Developing rapport makes a lot of sense because having a rapport can make learning more enjoyable and quicker. By having good rapport you become a signal for enjoyable experiences. You are a signal that says ‘you can get things you like from me’. A benefit of investing in rapport is that the momentum you’ve build up can carry you through difficult times. You may well notice the person is happy when you’re around.

How we support individuals is guided by how we interact. A bad rapport can result in insensitive support.

Task One on p.22 sets out how we begin to describe what good interaction looks like. Rapport is key to good support.

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Clinic: real life issues and shared solutions

The above topics are often useful in identifying elephants in the room that might influence challenging behaviour. Before reaching for a detailed assessment to understand challenging behaviour, we can gather good clues about what the person needs for a good quality of life by asking about

Choices How the person is supported Quality of life Rapport Communication Activities Health & Well-Being

Asking such questions of as many people as possible can show us where we might be able to modify our support in order to avoid or amend situations that lead to challenging behaviour support or that can improve quality of life.

To address challenging behaviour, we often have to focus on improving quality of life.

Notes:

Task One

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Doing is better than reading about things, especially if you wish to learn by applying the ideas we’ve discussed. Here, then is a task. Work with one individual you support in order to complete a Preferred Interaction Profile (PIP). The final product should be a simply worded summary document that avoids jargon or medical terminology, and that describes someone in human terms.

PIPS are quick guides to introduce someone to new workers or others. They usually are no more than five pages long, and every one is different. You might have experience of similar documents such as pen portraits.

Below are some prompt questions for the PIP.

Background What do we know of this person's history? What are their experiences? Where have they been living? With whom? Have they had experience of institutional care? Are there particular cultural or religious considerations? Any particular health or well-being concerns?

Activities What are the person’s preferred activities? What are their non-preferred activities? What is their timetable like? What do you think they might like to try? List five things the person likes, five activities, five people, five foodstuffs. Describe a perfect day for the person How long does the person stay on a single activity?

Relationships Who has the best rapport with this person? What guarantees the person a good day? How many people who are not paid see the person every week? What does great rapport look like? What does bad interaction look like? What induction do staff receive that encourages the learning of good

rapport? Describe happy behaviours Describe unhappy behaviours

Body Language Where do you stand when supporting this person? Where do you stand when making requests? Do you achieve eye contact? - How do you get it? Do you use signing? - Can all the staff group sign?

Verbal Engagement

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What is the person’s level of understanding of speech, signs, of symbols, of pictures, of situations?

How do they know what is coming next? How do they know what you ask them? Is it important to tell them about the size of a task (its beginning and

ending)? How are you going to do this? How do you get information from the person? What do they like to talk about? How could conversation be supported? (What about photographs,

objects of reference or communication books?)

Support How can we reassure the person if they appear anxious? What does anxiety look like for the person? What opportunities are there for making choices? (Both in everyday life

and as part of more important decision making processes) How do we present choices? How do we know what they have chosen? How do we know if the individual prefers some staff over others? Do they choose their support?

Preparation of Activities Size and length and complexity of tasks. How able is the person able to wait? Would routine scheduling of tasks be helpful? Would occupational aids be of help? Is the "sandwiching" of tasks helpful? (i.e., easy, hard, easy, or preferred,

non-preferred, preferred)

Motivation What motivates the person? How do you incentivise the person? Do you reinforce effort or near approximations to success? What is most important to the person?

Challenging Behaviour What challenging behaviour is common? What do happens? How to people respond? i.e., avoid/ignore/redirect? Is there a consistent plan everyone follows? Are there 'known' triggers that can be avoided or amended?

The completed PIP can help you consider environmental factors associated with challenging behaviour. You may note poor interaction is a predictor of problems. In which case your intervention is clear: change how you interact.

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Notes:

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Positive Behaviour Support (PBS) is a multi-component approach to understanding challenging behaviour, pre-empting it, and responding to it. Whilst it is very much influenced by, and makes use of behavioural approach, PBS does not solely rely on one approach.

So what does PBS do? It bases interventions upon an understanding of social and individual factors that influence challenging behaviour. Its goal is to improve the quality of life of the individual to reduce challenging behaviour.

This is why you were asked to complete the Positive Interaction Profile.

PBS aims to ensure interventions are value led: we aim to teach new skills, and change how we think about and work with the person.

What is a reduction in challenging behaviour?Some behaviours are considered challenging due to their frequency. We might define our interventions a success if such behaviours occur less often. Other behaviours may be thought challenging due to their duration, so we might aim to reduce how long a behaviour occurs. Some behaviours are an issue due to the intensity of them. We might then try to reduce the impact or severity of the behaviours.

We can achieve the above by teaching alternative behaviours that meet the same outcome for the person whilst being easier to perform. We call this functional equivalence.

How do we improve quality of life?Quality of life is different for different people, but we can construct a broad matrix of the domains it might consist of – some of which are more important than others for different people.

Way back in 1987 John O’Brien attempted to describe a good quality of life for adults using services. He suggested a service knows it is working toward delivery good support if certain accomplishments define the work:

Dignity & Respect Competence Community Participation Community Presence Choice.

A plan to support behaviour change must also address these five accomplishments.

What are the working assumptions of PBS?

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Behaviour change can be maintained only when a quality of life is lived and competently supported. In PBS we aim to not ‘fix’ the person but the ecology. If a person can communicate well but isn’t listened to, we are likely to see more challenging behaviour appear.

PBS bases its decisions on data as well as an understanding of what the person wishes.

The collection of accurate information is vital in establishing why the person behaves in the way they do; it is no good being the best observer in the team if the information isn’t recorded. The collected data should be collated regularly, and the analysis fed back into interventions. The records kept are legal documents and must be accurate and verifiable. It helps to have staff analyse and ‘make sense’ of the data rather than hand it over to other people.

By not keeping accurate records, and by not communicating effectively with everyone in the team, service users and staff are put at potential risk. Measurement is important to help us understand the problem, to plan for its reduction and replacement, and finally, to help evaluate the success of intervention. The frequency, duration and intensity of a problem can easily be misjudged- for example, “Tony eats all the time”, or “Kelly talks about body piercing all the time”, but the reality would be something different. The absence of the behaviours is often just as informative as when the behaviour does occur.

Methods of data collection includeDirect Observations

• direct observation (where the observer watches & measures without being involved)

• participative observation (where the observer works with the individual and thereafter records their impressions or findings)

• variation on the above: one person can interact with the person, whilst another observer records contemporaneously or at intervals, what occurs)

• video: lots of video is taken and analysed at a later date. Indirect Methods

• formal interviews with staff • formal interviews with user • formal interviews with other stakeholders • checklists or questionnaires • examination of records such as ABC records.

One of the first things you might wish to do is to interview people who know about the issues and the person. The approach we’re recommending to do this is a structured interview known as O’Neill Functional Assessment Interview. We’ve given you blank copies of the interview schedule and an example of a completed one. The interviews usually take one to two hours to complete, and most practitioners

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complete two with different individuals. They then compare and contrast the information from these two sources.

Interviews are a way to get initial information. They are insufficient to base interventions on. Just relying on records, or relying on interviews, is insufficient. You need to check what people tell you against what you see yourself. But typically interviews (and questionnaires) can help you work out where to focus your own observations. Interviews are also helpful because they include people in your exploring. Often the last person a behavioural advisor speaks to is the actual person themselves, their parents or friends, or support staff. They base their ideas on discussions with managers or senior staff who don’t know the person so well. Thus many recommendations of methodologically flawed and don’t work so well. Getting informed information is key as it guides where to look in more precise detail.

Today we will consider examining records (ABC data) – as this will show you how you might take meaning from records – and direct observations – we’ll be using the O’Neill Functional Assessment Observation Form (FOAF). We’ll also briefly discuss scatterplots and questionnaires, including interviews. At the end of the day we’ll talk about bringing all the information together to produce a summary statement (a best guess or hypothesis) about the challenging behaviour.

ABC Data

One the standard initial information collection techniques most of you will have encountered is the infamous A-B-C record chart, short for Antecedents-Behaviour-Consequence. I say infamous. One of my regular frustrations is being presented with eighteen months of ABC charts that have been filed and never examined. I have actually observed staff endeavouring to complete an ABC chart at the end of a shift (doh!) and say ‘Oh I’ll just copy the last one’.

Now, ABC are a complete waste of time unless they are completed as soon as possible following an incident (human memory being the awful thing it is), and if they are accurate. It’s also frustrating to note that all too often they remain unexamined for weeks, months and even years. “Why are you writing up ABC charts that are never analysed?” I’ve asked staff. Their eyes become dull. “I don’t really know,” they say, “but I get shouted at if its not filled in.”

They are doing it because their managers tell them to do it. And the managers tell them to do it because collecting ABC data is what people have always done. It is often the case that not much happens with the data.

This doesn’t help staff remain motivated to complete them. And it makes ABC records pointless. No one ever intended for ABC data to be collected permanently. They were intended to be probes – discreet assessments for a brief period of time.

ABC data (or three-term contingency data) were intended to identify antecedent events that predict challenging behaviour, and that are associated with specific

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consequences. That is their only point: to collect information about functional relationships.

All too often they become a standard form to be completed… like forever. Which is a bit pointless, as we’ll discuss. Use ABC forms sparingly, but keep them accurate, and analyse them yourselves. Then feed this info back into your interventions.

When you analyse ABC records, you’re looking at information obtained through indirect methods (that is, things seen by others). By indirect methods, we refer to scatter plots, three term contingency records, and other methods of data collection carried out by other people.

Indirect observations tend to be fairly rough and ready in actual clinical practice, but they do provide you with areas to further explore. Indirect observations could also include looking at organisational records. For example, if you’re trying to see how much of an impact behaviour has upon staff, you might look at sickness records, incident reports, staff turnover, supervision summaries, and so forth.

ABC records are usually written accounts of certain behaviours, what predicted the behaviour (or triggered it) and what followed it. An example is produced below:

ABC records allow an observer to organise anecdotal or descriptive information inasmuch a way that patterns of behaviour often become clear. An ABC chart might be individualised to contain several predetermined categories of antecedent, behaviours and consequence events, along with space for narrative observations.

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ABCs provide the following data: estimated rates of behaviour, likely times when behaviour may be more probable, situations predicting the probability of behaviour, identification of commonalities between behaviour episodes/incidents, and the impact different behaviours have- activities withdrawn, for example, or attention. ABC data provide hypotheses which may be further examined.

Exercise: for each example, identify the antecedent(s), the specific behaviour and consequence maintaining the inappropriate behaviour.

1. Rachel's father asks her to pick up her toys and Rachel refuses by saying "no." Her father asks two more times without success and then he picks up the toys himself.

2. Tammy often rocks and bangs her head against the wall as her mother attends to her new baby sister. Tammy's mother reacts to this by immediately hugging and attending to Tammy, often offering her food and toys.

3. Archie has a language delay but has been observed to use some appropriate language at school. Archie's parents have not been able to elicit the same language at home. Before giving Archie something he clearly wants, his parents prompt him to use his words to ask for it. Archie responds by screaming until his parents finally give him what he wants.

Once you have several ABC charts you can analyse them. To do this, first separate the forms by the behaviours if that is possible. This means an ABC record featuring two or more behaviours (in the example) might feature in two analyses. Once you have a pile of ABC for each behaviour, you can then code. This involves make a note of common antecedents, and common consequences. Below is an example of a coded ABC record:

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To code you create a separate sheet and make a list of different antecedents (in the above example A1 is a staff member (Ray), A2 is noise, A3 is the presence of many children, and so forth. In the example, two behaviours are found: B1 is screaming, B2 is hitting her head. You do the same for consequences. In the example, C1 is removed/escape from situation, C2 is attention/reprimand, C3 is tangible item, C4 is attention/treatment.

Once all your ABCs are coded, you can add up the total number of A1s, A2s, etc, that are consistently associated with certain behaviours. Ditto for consequences. Your analyse will thus produce a brief statement such as

“In twenty ABC records examined, when it is noisy (10%), and there are many children (20%), when she is asked to wait (90% of records) Mary screams. This results in Mary leaving the situation (90% of records).”

You might even want to graph these data. Below is different data concerning a different person.

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The whole point of graphing is to help people see the meaning of your information quickly and easily. The only pointing of understanding the meaning is to inform your actual support strategies. If in the example above you can say demands predict self-injury and escape from the demand follows, you will want to change how and when support staff place a demand on the person. If from the above you know the person escapes an activity (or a person!) through SIB, you might want to teach the person a better way of asking for a break, and teach staff how to support the person better.

Knowing this informs your interventions (day three).

You don’t need to keep constant ABC records. ABC records are needed to explore the function of behaviour. (You can also use ABC to record non-challenging behaviour, such as happiness, such as doing an activity well.)

If you just need to know the rate of a behaviour – how often it happens – or when it happens (hot spots that predict a behaviour is likely to happen), you might simply need a scatterplot.

“Guiding our efforts to understand these behaviours better has an implicit assumption; that such behaviour problems are not abnormalities. Instead, these responses are reasonable behavioural adaptations necessitated by the abilities of our students and the limitations of their environments.” (Durand, 1990).

Environments, often, that we ourselves would find unacceptable

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Scatter Plots

Often, initial observations can be accomplished through the use of a scatter plot. The purpose of a scatter plot is to identify patterns of behaviour that relate to specific contextual conditions. A scatter plot is a chart or grid on which an observer records single events or a series that occur within a given period. Scatter plots take various forms, depending on the behaviour of interest and context, but it can help us work out where we might want to focus our attention when we do direct observations.

Below is a scatter plot for Mary’s screaming behaviour. Each mark indicates screaming has been observed.

Mon Tues Wed Thurs Fri Sat Sun8-10am /////// //// //// /////// /////10-12am / // /// // //// /// //12-2 ////// /////2-4pm4-6pm /6-8pm /// //// /// //// ///// // ///8-10pm /// //// // /

What does this tell us about Mary’s screaming?

Direct Observations

Watching events happen in real time is often a useful way to see if what is recorded is actually happening. Remember the only point of direct observations for challenging behaviour is to check what predict and what follows the challenging behaviour – you’re looking for evidence of functional relationship or contingencies – A predicts B predicts C.

The rule is simple: the more time you observe, the more events you can observe, the more data you have to interpret and the more robust it is. The technique we’re recommending is O’Neill’s Functional Observation Assessment. We like it because despite first appearances, it is very simple to use and interpret. It provides event counts of behaviours, and it collects functional relationship information (a direct observation ABC). (I once heard a behaviour specialist say this tool is like David Beckham: perhaps not so sophisticated at first appearance, and covered in weird symbols, it does have hidden depths and is also quite useful to have on your team.

...behaviours may be

terribly dangerous,

but their function may

be legitimate

(Donnellan et al,

1988).

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We’ll spend some time learning this tool. If behaviour assessment had Desert Island Disks, and the disks were assessment tools, this would be the single one we’d opt for.

It often is useful to have a second person verify your findings. They can do this by observing with you, or if you’ve used video to analyse later, have the second person watch the same video. If you find the same events as the other observer we can say our findings are reliable, and we can be confident our of findings.

Once you have completed FOAF you can look for common themes, as set out below.

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Question: how might you interpret the above?

Bringing It Together

We can summarise the information into summary statements. We compare what the ABC data tells us to what the FOAF data says.

At the end of our assessment we can usually describe• what the challenging behaviour looks like• its dimensions – how long, how frequent, how often• when, where and with whom it is likely to happen• setting events and antecedents• consequences maintaining it.

An example would be:

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When Tony is tired or hungry, he is more sensitive about being asked to do housework, and he’s more likely to huff and swear, and the consequence is he escapes doing the housework.

We can fold in the findings from day one: we can describe a good day, a good interaction, a good quality of life, and see how providing these things influences the setting events of challenging behaviour. We might even get some ideas about neutralising setting events, or making demands less of a problem for Tony:

When Tony is not tired or not so hungry, he is able to cope with being asked to do housework in a friendly and funny manner, and he’s more likely to do the housework with support and the consequence is he gains attention, feels good the job is done, and enjoys being in a clean house.

You can see that support and intervention is directly drawn from the information we have gathered from our assessment.

Task Two

Work with the individual you worked with to complete a Preferred Interaction Profile (PIP).

You need to:a) Complete ABC records or a scatterplot on a challenging behaviourorb) Complete ABC records or a scatterplot on non-challenging behaviourandanalyse/code the findings, summarising your results. You can graph or write your discoveries.

If you can:Complete about four hours of observations using FOAF.

Having completed the above, write a summary statement much like the one at the top of this page.

“The PBS approach refers to those interventions that involve altering deficient environmental conditions… and/or deficient behaviour repertoires… increases in positive behaviour, lifestyle change and decreases in problem behaviour define the core of PBS…”

(Carr et al., 1999)

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Remembering there individual is more than data. Ask…

Who is the person?

What do they enjoy?

Describe the challenging behaviour:

Setting Events: What sets the scene for the challenging behaviour?

Predictors: What ‘triggers’ the challenging behaviour?

Consequences: What follows the challenging behaviour?

What is your evidence for all of the above?

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You can use the above to summarise all the findings from the different sources.

Name of Focal Person

Target Behaviour

Your Name Method Date Information

CollectedWhat Is Suggested?

Interview(s)

Direct Observations

A-B-C

Other

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Below is an example of a summary statement. You’ve collected a lot of information and stories, and now you need to summarise your findings.

Once we have a summary statement and are fairly confident about it, we can design support strategies that address each element of the contingencies, so interventions to modify setting events, strategies that amend predictors, emergency strategies that keep people safe and negate the benefits of the behaviour itself, and strategies that reinforce alternative or competing behaviours.

The goal of PBS is not just reducing specific behaviours. The approach recognises that "problems" often reside in not providing tailored and comprehensive skilled support. The amelioration of the behaviour is primarily achieved by the creation of responsive environments and building new skills, rather than simply attempting “to stop” the person. It usually requires more than one type of “intervention”. It aims to support people to "get a life" and keep a life and to build skills and understanding in those supporting the focus person, and this is why PBS interventions are multi-element: they focus on interventions that provide good support not just advice about emergency situations. The goal is to not need challenging behaviour.

Strategies fall into the following domains: Strategies setting out how to support someone during a crisis

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Strategies to teach alternative behaviours that compete with the challenging behaviour

Strategies that change the environment to better suit the individual Strategies that amend or avoid setting events and predictors.

Intervention strategies mean changing social systems /environments, not simply the person. Meaningful lifestyle changes are the goal: intervention may require permanent changes in how staff work with people. To achieve this often managers and leaders change how they support those supporting people whose behaviour challenges the system. PBS is then quite ambitious if introduced fully.

Behaviour support strategies are of two kinds… reactive (when we decide how to respond to the target behaviour) and proactive (when we pre-empt).

Reactive strategies are the most common. They are also the most devious for interventionists to grapple with. Reactive strategies aim to stop a behaviour- to keep people safe, to divert them and so forth. Now if they do temporarily cause a behaviour to reduce or stop, reactive strategies can be reinforcing for staff using them. Staff are often negatively reinforced in using reactive strategies.

However, reactive strategies may not be constructive- that is, they don’t teach the focal person any alternative skills- but they do teach staff. So this may account for why places where physical interventions are common place, are difficult to change. People use what they know works- even if they work only temporarily.

To achieve the same goals in life to which we all strive- to obtain things we want such as attention,

affection, and materials, and to avoid things we don’t want such as pain, discomfort, boredom, and

failure- these individuals have learned to behave in ways that we label as problematic. We have

unwittingly taught those referred to as having disabilities… to behave in socially maladaptive ways to

secure their entirely human wants and needs. …our goal must change from the elimination of

problem behaviours to understanding their function so that we can craft an intervention designed to

teach a new form of behaviour that is at least as successful in achieving the identified function as the

old, more coercive form. The implications… are revolutionary.”

Halle, J.W. (1994) Forward to Carr, E.G., Levin, L., McConnachie, G., Carlson, J.I., Kemp, D.C., & Smith, C.E.

Communication-based intervention for problem behavior: A user’s guide for producing positive change.

Baltimore: Paul H. Brookes

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Every good intervention plan comprises some reactive elements (to keep everyone safe) but the bulk of interventions should be proactive.

There are three kinds of proactive intervention. The most fundamental aim to change how we organise the environment- how we think about interaction, rapport and communication, and how we schedule activities. These are called ecological interventions. They ease the fit between the person using the service and the service.

The PIP you completed may lead to changes in how someone is communicated with and how they are supported: these are ecological interventions.

The second element of proactive strategies deal with artificial reinforcement. We sometimes need to use reinforcement to help the person differentiate between preferred behaviour and non-preferred.

These are called focussed supports. They tend to be temporary interventions, and are sometimes quite complex. We tend to use them at specific times. For example, if we know the person finds handovers/transitions problematic, we might introduce a focussed support intervention purely for these times.

One of the basic methods is to reinforce for the omission of the behaviour of concern, or reinforce a competing behaviour. We might even reinforce for lower levels of that behaviour. We’ll cover this in a bit more detail during the workshop. But imagine the transition period: we might arrange to help the person cope with these times by:

Ecological Change: have someone to be with the person during this time, engaging in a preferred activity.

Reactive Strategy: at these times, we might employ a more active kind of support, active listening. We might ensure the person has preferred items available to divert possible behaviours escalating.

Focussed Support: we might have a schedule to reinforce the person for engaging in an activity rather than the problem behaviour during handover. If the person remains focussed on an engagement or activity and calm during handover, we might schedule additional, artificial and extrinsic reinforcement for each two minutes they stay calm or busy.

Focussed supports are quite technical, and we’ll discuss them next time, but the example above is just an example. The time people are asked to wait is carefully calculated, and not random. But you can see in the example above how different elements of the multi-element model fit together to achieve the outcome.

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The third element of ‘proactive strategies’ involve teaching new skills, perhaps about coping, or self-management. Often we want to teach alternative behaviours that compete with the challenging behaviour in order to make it obsolete.

There are a few types of skills to think about. The first is about teaching the person general skills that can help them in their lives. Often, introducing general communication skills can help enormously offset the ‘need’ to challenge.

A second type is called functionally equivalent skills. This broadly means teaching new ways of getting the same thing that the challenging behaviour achieves.

Taking the transition example once more. In addition to our reactive, ecological and focussed support strategies, we decide to teach a functionally equivalent form of communication. We teach by reinforcing the competing behaviour.

In this example, we might discover the reason the person becomes anxious and aggressive during handovers is that he/she doesn’t know if they are being talked about. We might then seek to reinforce a communication alternative to aggression. Rather than hit out at us in order to disrupt or access the handover, we might reinforce the person when they ask appropriately.

The new alternative behaviour should be quick and easy- take less effort than the challenging behaviour. We might think of these as competing behaviours to the challenging behaviour. We can’t unlearn things but what we can do is learn alternative or competing behaviours.

Think of the ways you gained attention from people when you were a young child. Now think of all the ways of gaining attention now. Different skills, a wider repertoire of methods, but the same end.

So the best intervention packages contain attempts to teach the person alternatives: New skills.

Focussed Support strategies aim to gain fairly rapid control over challenging behaviours because of the risks associated with challenging behaviour. Ecological Strategies make the environment fit for the person. New Skills teach alternative behaviours that compete with the challenging behaviour. Reactive Strategies help describe how we keep everyone safe if challenging behaviour occurs: they tell us how we should best respond.

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Some Examples

Ecological interventions involve Changing how people are supported: “interactions & fun” Changing how communication is organised: “speaking the same language” Changing what people do with their time: “active support” Changing how we support staff: “dispersed leadership & involvement” Improving rapport: “staff as generalised reinforcers” Ensuring the person belongs: “relationships & networks not just paid staff” Ensuring we avoid or amend setting events that lead to sensitivity to certain

predictors of challenging behaviour: “avoiding wars by avoiding triggers”. Such strategies are known as antecedent interventions.

Ensuring the physical space suits the person: “my home” Ensuring the physical space is interesting: “I would choose to live here” Ensuring there are things to do and that days & weeks & year is predictable Noise, space, light & heat Ensure access to tangible items such as food & drink & activities Ensuring the person is liked Enrichment: ensure the person gets what they need as everyday support. If a

person challenges to gain attention, give attention at other times. This antecedent intervention weakens the functional relationship between specific behaviours and specific consequences, thus reducing the person’s need to rely on that behaviour.

New Skills strategies involve Teaching alternative behaviours that compete with the challenging behaviour General strategies that increase independence and choice New skills must be easier to perform, quicker to gain the same outcome as

challenging behaviour behaviour, and be able to performed in different places with different people.

The key issue is reinforcement. You need to know the function of the challenging behaviour to effectively run a New Skills strategy

Focussed Support strategies involve Competing behaviour is differentially reinforced: “a reason for choosing

alternative behaviours” Reinforcement of challenging behaviour is reduced or limited: extinction

programmes are best linked to teaching alternative competing behaviours. If you simply stop or reduce reinforcement for challenging behaviour you will likely see a temporary increase in the challenging behaviour that may be dangerous and unwarranted

Stimulus control: behaviours are often under the control of environmental stimuli (think red lights at traffic junctions). If a person is constantly asking staff questions of staff one member of staff at a time can wear a badge or sign (a stimulus) that acts as a signal they are the person to ask.

The key issue is reinforcement. You need to know the function of the challenging behaviour to effectively run a focussed support strategy.

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Reactive Strategies include Listening to what the person means not what they say (active listening) Responding to early warning signs that situations might be spiralling out of

control Changing the narrative: some people work to a script – this leads to that

leads to something dangerous. Can you change the script? Divert to preferred activities or people or topics Change staff to a preferred person Give the person what they’re asking for Say sorry Novel stimulus: sing, dance, fake a coronary, tell a joke, ask a question Share solutions: ask the person to help solve the growing conflict Go away: walking away helps some people Sometimes natural consequences just make matters worse: the person would

have learned already, surely, through natural consequences, but clearly hasn’t. Can you avoid natural consequences?

Change the situation by asking them to do something they love The key issue is reinforcement. You need to know the function of the

challenging behaviour to effectively run a reactive strategy.

An Example Exercise

Functional relationships were identified through interviews and observations. They showed the following:

When Mary is feeling unwell, and has missed breakfast, when asked to get ready in the morning, she will try to slap staff. This often results in the request to get ready to be withdrawn (staff leave). At times, staff insist Mary get ready, and this sometimes leads to Mary’s behaviour escalating into scratching and biting herself.

Setting Events:Feeling unwell, not eating breakfast

Predictors: Asked to get ready (wash, teeth, hair, clothes)

Behaviours: Tries to slap staff

Consequences #1: Staff leave and demand escaped

Consequences #2: Staff increase demand. This leads to more intense aggression.

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In groups, write up potential strategies using the following headings to organise them:

Setting Event Interventions (Ecological Antecedent Strategies)

Predictor Interventions (Ecological: Changing the Antecedents)

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Behaviour Interventions (Reactive: Keeping Everyone Safe)

Behaviour Interventions (Focussed Support)

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Behaviour Interventions (New Skills)

Consequence Interventions (Reactive/New Skills/Focussed Support)

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Implementation of PBS

Implementation is the key element of good behaviour support. Here’s a heads-up. To implement anything well doesn’t mean popping into a service, making recommendation and presenting a report, and disappearing for six months. Such pigeon management has no evidence of effectiveness. To implement means to be present physical and psychologically as often as required. To implement means to not work towards people relying on you as a superhero but to help them learn and make independent decisions within a network.

To implement well requires us to understand why things are currently done as they are: you need to understand that the issues staff experience or show are just as functional for them as challenging behaviour is for those whose behaviour challenges the system. Services are not blank canvases upon which you paint. They are acting as they do for very logical reasons even if the outcomes are unproductive. Jim Mansell used to warn his students that even dysfunctional services were functional for someone. A canny practitioner learns to ferret out those functions. For example, you may be speaking to a manager about changes in practice, only to later discover the manager has actually not power or ability to enact anything he/she agreed to: the canny practitioner identifies who are the key players, who holds the power, who is the keylog to free up barriers to change. A canny practitioner is a practice leader: they teach by showing and expecting.

To implement a change in practice you need to identify what is happening now and why it is happening, just as you would for challenging behaviour. What you’re doing is seeking to understand why the current way of doing things – the culture – is as it is, prior to introducing changes. By doing this you make the changes fit for the environment and so increase the likely success of any change.

A psychological contract is said to be present when people are employed to do a job of work. It is about expectations organisations place upon us, and vice versa. Not only do employees have obligations and duties to the organisation that make them accountable, but the opposite is also said to be true. In a way, a psychological contract is the perceived promises and conditions an employee or group of employees feel have been made.

If any innovation or change in culture or expectations is imposed a little casually, the psychological contract can easily be broken; teams pull themselves apart and work to different agendas. Alternatively they resist the change and the change leader. They actively work to thwart the innovation. The people to suffer are those using services and staff. It takes a long time for a manager or leader or practitioner to develop trust and partnership, but about thirty-seconds to screw it up.

The issue here then is very real: what some staff signed up for, some of them many years ago, may be radically altered in any change. Not only have physical locations been ‘tendered out’ by commissioners, but so have the people living there, and so have many staff, as if they were no more than chattels. This raises a challenge for

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new organisations endeavouring to build better systems upon the ruins of old systems. Often organisations do not give enough thought to the fact that existing systems are not blank canvases upon which new policies and practices can be written, but are complex spaces with powerful ways of working and thinking embedded.

If the psychological contract is perceived to be broken, then it is likely staff will protect themselves and their practices. They may justify to themselves that the way they currently work is proven to be in the best interests of the people they support. Resisting in some fashion the ‘new’ organisation/policy is legitimate for them. It is important to know the psychological contract is implicit and unspoken until such time as it is perceived to have been broken, at which time staff often feel violated, ignored and not respected, and then suddenly, things become explicit.

The psychological contract as a construct has a long history, and has often been employed to understand the complex issues arising from grappling with organisational psychology accounts of high turn over, resistance to change, job satisfaction and security, commitment to organisations, motivation, competence of staff and management and productivity. As such it is most familiar to those focussed on human resources and related disciplines. But for managers, knowing about expectations and ‘contracts’ for staff can help them identify potential barriers.

The golden rule for those seeking change is to ensure mouths are shut and ears wide open before doing anything.

You’re Actually A Teacher

Leaders and support staff, PBS practitioners and professionals, are teachers. The best teachers get the best results from the people they teach not by issuing directives or memos, but by using

Science! Well, evidence-based approaches to support best practice Relationships! Actually, the skill of developing a rapport with people,

fostering encouraging relationships that create a constructive culture; we do this by knowing something about the people we work with: knowing someone’s life outside of the work is important to them and influences what they do, how they think, what they feel

Inspiration! Good teachers have ‘the knack’ to inspire, have fun, listen, and flow with the developing narrative of the situation. They aren’t so much King Canute ordering nature to obey them, more surfers, crafting their path from the natural forces operating (Halvorsen & Neary, 2015).

Managers ensure things get done according to protocol, leaders define, embody and enact the meaning of the work that produces the protocols, whereas teachers and practice leaders discover learning and teach their learning through doing – they lead because they are allowed to lead and teach by those they work with. So rank & status is less important than you might think. It’s the leadership arising from acclamation of skills that counts for a lot in PBS, not the size of your MSc.

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Task Three

Work with the individual whose behaviour you’ve examined through ABC analysis or FOAF. You should have produced a summary statement, and are ready to speak with others to create together possible support strategies

You need to: Speak with people about ways to support the individual.

o You want to share your understanding of what might helpo You want to listen to others to hear their ideas & understanding

Summarise the factors influencing the culture of the place the individual lives within.

o What is important to people? o Why do they do what they do? o What do they think causes the behaviour?

Sketch some potential support strategies thato Neutralise or amend setting events (i.e. predictable routines, health,

communication)o Neutralise or change predictors (i.e., interactions, preferred people or

activities or items, communication)o Describe ways to avoid challenging behaviour o Describe ways to support the individual during a crisiso Describe alternative and competing skills to make the challenging

behaviour obsoleteo Describe how to better support the staff.

Remember, interventions not based on function aren’t as successful as those that are. If you’ve no clear idea about the function of the challenging behaviour, you’ll struggle to teach alternatives. Even so, general improvements to the environment, communication, relationships and activities can work wonders. And no staff ever suffered by being better supported, lead or listened to. Neither did you.

Most people you support won’t need detailed assessments to ascertain the function of behaviour and so they tend to respond really well to the fundamentals of good support: great rapport, thoughtful communication, having their interests enabled, living a good life, competent staff who know how to listen, enable and teach.

But some people are more complex, and their reputations often so severe we are blinded to the obvious ‘elephants in the room’: we see only the aftermath of behaviour, not the early warning signs. Their reputations are so severe we doubt ordinary approaches will work: we doubt not only ourselves but also our ability to support the person well by getting to know about them and doing the basics to make their life interesting and enjoyable. But here’s the thing: you’re not alone, you can call on the experience, knowledge and support of others. Working alone is often detrimental to your well-being and the quality of the work you produce, so just make sure you can call on others and together move forward. Share the responsibilities,

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share the knowledge, share the leadership in a network. Working collaboratively is one of our evolved behaviours that can truly be beneficial.

So don’t ever forget the basics: PBS is about delivering the life the person cherishes and flourishes within. We can get caught up in the hoo-hah of the technology of behaviour change to an extent we forget to see the human in front of us or within us.

To implement PBS: It must be seen as more relevant and more beneficial to people than current

approaches (it is easier, quicker and more effective) It must link with other approaches being enacted: for example, if the

organisation is working toward person-centred active support (PCAS), it should be clear how PBS approaches and support strategies fit with PCAS

Therefore you need to plan how to implement PBS All aspects of the organisation must have knowledge of PBS whether at a

basic level or a more sophisticated one: coaching, training and practice leadership are essential not only to the propagation of PBS ideas, but practice. Training is insufficient. Planning is insufficient. Doing is required. Reflecting on the outcomes of doing must be a part of an implementation strategy.

Research shows for the general uptake of PBS organisations should ensure Effective training and mentoring Ongoing support to distil the learning arising from doing Efficient teams and leadership Regular update of skills of implementers People seeing the organisation is responsive to individual needs and staff

needs (McIntosh, Lucyshyn, Strickland-Cohen, Horner, 2015).

In terms of supports for individual plans, implementation can often benefit from ensuring everyone involved understands the importance of the approaches and the relevance to their own work. If you seek to implement a PBS plan for a specific individual it often helps to

Ensure the strategies fit with the context Staff or family buy-in is essential, so involving them in assessment and

strategy design is helpful to achieving this Having good relationships with key individuals in the support team Meet the wider goals of the individual in terms of relationships, rapport,

quality of life and ambitions Staff are mentored and supported to follow the plan Staff are involved in reviewing data and checking benchmarks Are well led and supported during difficult periods Staff know how to gain support.

One vital ingredient to ensuring implementation fidelity is to clearly understand the reinforcement available to staff to carry out the support strategies. If people are not

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following plans, it is reasonable to consider why this might well be the case. Are the plans too complex or difficult? Do staff lack the time? Do they not buy-in to the logic underpinning the plan? If the consequences of giving-up on a plan outweigh the consequences of following the plan, the plan will be abandoned or subverted.

It might simply be that staff are too cynical: exploring if staff believe change can happen, that the person they support can learn, seems key. If staff do not believe in the capacity of the person they support to learn new ways of behaving, staff will undermine the strategies. This is why embedding in any mentoring, practice leadership or strategy plan and training, positive but realistic optimism about learning is so very important. Challenging beliefs that impinge on optimism should be part of any training and mentoring. Addressing attitudes as well as practical competencies result in staff more able or willing to follow PBS approaches (Hieneman & Dunlap, 2015).

Practice Leadership

The vital importance of practice leadership as opposed to management has been well established in the literature. But organisations often prefer transactional managers and administrators (who tend not to ask awkward questions of the status quo) rather than transformational or skilled leaders (who tend to be typified by challenging practices and structures). Practice leadership requires enablement from the wider organisation: practice leaders need to be tenacious, skilled communicators, demonstrators, able to direct staff,

Management & leadership by presence, by walking about “defines the job, provides the training, mediates the stresses, creates the culture, helps people find the personally satisfying rewards of direct support work, and establishes a well-functioning work environment” (Hewitt & Larson, 2005, p.113).

It is worth considering whether your job allow you to lead, whether your job description matches the reality, how much time is allowed you to show staff how to work proactively with people they support and to ask a simple test question: what matters most: getting the rota done or measurements of quality of life?

It is therefore worth examining the job description and performance expectations of managers: do they explicitly cover the competencies associated with practice leaders? Hewiit et al (1998) provide a competency framework, but others exist:

Enhancing staff relations, well-being, and competence Providing direct support, role-modelling best practice, reviewing

performance against evidenced ways of working elsewhere Building inclusive communities and enhancing networks of people using

provision Supporting planning and monitoring of practice standards Managing staff Lead training and development

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Maintaining design, property and access to community Protecting health, safety and well-being Financial management Rota and payroll Co-ordinating day supports and activities Co-ordinating policies, procedures and rule adherence Office work.

This list illustrates the exceptional skill mix that is found in exceptional leaders. Evidence suggests that such leaders are not born, but are made, not by qualification, but by experience.

After years of research, my old Director at the Tizard Centre began to be followed by a lurking suspicion: it followed him all over Europe and Australia, he noticed it at home, at work, at play. He suspected… “Staff feel that management’s true objectives are not congruent with the espoused care objectives and that trained behaviours deterioriate quickly at work” (Mansell, 1996, p.57).

Mansell and colleagues began to suspect an inverse relationship between seniority and competence at hands on work with clients: “just as house leaders become less skilled and less involved in work with clients because they spend less time with them, so their managers are even less use as role models” (Mansell, 1996, p.57). It turns out his qualms could be traced back many years to other social scientists, and to a man called Gilbert, who worked with Skinner but felt Skinner’s model was a little limited when it came to complex tasks of productivity. “I have found repeatedly that a culture that does not work well- in which people are unhappy, inscure, unproductive, and uncreative- was designed by a manager who did not begin with careful analysis of its goals and values. This analysis, this teleonomic engineering, pursues a method astonishingly different from that of the sciences… The engineer knows in the main what the goal is, and begins by making a design of that end point” (Gilbert, 1978, p.103).

In the same way we can apply PBS to individuals, we can apply its principles to staff and organisations.

Questions: What is the reinforcement for commissioners and care managers? What reinforcement is operating for service organisations? What reinforcement is operating for managers? What reinforcement is operating for staff? What are the punishers and reinforcers for innovators?

Quality

Skill comes from the Anglo-Saxon, meaning to ‘discern’ or ‘discriminate’ (Gilbert, 1978, p.305). These days skills means you have been obliged to sit through four

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hours of health and safety training and received a certificate of attendance and (presumed) competence if you’ve passed a simple test. It may also mean you’ve completed Fire Training via the Internet. Such programmes tend not to result in people competent at discerning or discriminating, merely reproducing what has been told them. Remember the Stanford Prison experiment? “Bad systems create bad situations create bad apples create bad behaviours, even in good people,” (Zimbardo, 2007, p.445).

David Towell edited a book called An Ordinary Life in Practice. In this book Roger Blunden wrote about quality. This was nearly thirty years ago. (1988.) Blunden suggested quality conscious services base performance indicators on their values. It’s not the number of teaching plans that count, but the quality of them in helping people learn. Blunden noted that for good organisations, the views and experiences of customers are the key concern.

Blunden argued organisations keen on maintaining quality should focus on process and outcomes, and that the structure of such organisations might be less hierarchical, more democratic, more fluid: “with small groups and task forces being formed around the solution of particular problems. The formal structure of the organisation would not be allowed to get in the way of achieving results. Staff would be actively encouraged to innovate and to champion new ideas. There would be recognition that not all new ideas would succeed. Failure would be tolerated and lessons learned from the experience” (Blunden, 1988, p.109-110).

Blunden found all stakeholders should be involved in, “defining and reviewing service quality” (p.110) and that “their active participation will help ensure that their interests are respected and that any decisions made are likely to be put into practice” (p.110). Giving people using services and those people doing the work in IDD provision a legitimate voice in how things get done can help construct a productive culture of practice, it seems.

Blunden argued one of the challenges for community services was the creation of a culture based upon shared values; you couldn’t simply employ anyone without actively supporting their learning through training, coaching and management. This meant good managers paid mindful attention to such things as recruitment, supervision, peer evaluation, and the embodiment by management and leaders of the values they sought to see put into action. Staff would see their managers and leaders enacting the values every day. Values would inform how things got done.

Blunden also cited the work of Gilbert, who argued that human organisations would do well to focus not merely on behaviour but on accomplishment. O’Brien adopted this model when he wrote of the Five Service Accomplishments in 1987. What people do is the behaviour. What people achieve is the accomplishment.

Therefore when reviewing the quality of services it is important not merely to consider what is written and what people tell you, not merely to measure the presence of items assumed to indicate quality but what is achieved. (Does the

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person have a care plan? Yes! Therefore this is a good service! No- it’s how it is written and how it is enacted to bring about the agreed outcome that indicates whether the plan denotes a good service.) It’s not the presence of a certain number of person centred plans but whether each plan is meaningful in contributing to achieving what the person requires. “It is unusual to see services being reviewed in terms of the extent to which they enable clients to expand their social relationships or learn and effectively use new skills,” (Blunden, 1988, p.111).

As a last point Blunden suggests helpful quality assurance systems should be geared toward action; all too often the wrong indicator is measured poorly and not much changes.

Blunded notes “the procedures outlined here seem little more than common sense” (p.114) but common sense assumes a lack of politics, a lack of agendas, and equitable power and focus. In this way, common sense is naive. What we know about politics in organisations, power-games in systems, is that resistance is fertile. Putting values into action is hard and it requires competent management and visionary leadership. “How often is most service organisations do senior managers concern themselves with the details of how the service is influencing the lives of its users?” (Blunden, 1988, p.114)

Involving Staff

My experience of many staff groups and teams, and in consulting to organisations, seems to reflect common threads found in the literature in that there are benefits to learning to listen to groups of staff, no matter how disassociate or angry they present:

it gives permission for staff to contribute, to feel their views are worthy of being heard. (If people are unheard, they may express their exclusion in damaging behaviours aimed at everyone, including themselves);

it emphasises that understanding and responding to common issues is a shared endeavour. (Relying on ‘experts’ to make sense of events can belittle the knowledge present in the group);

it opens a dialogue and a culture of discussion; it can potentially pre-empt the development of unhelpful practices by groups

of people who may feel abandoned by managers or professionals or ‘at the bottom of the knowledge pile’ by drawing out their genuine experiences, hopes and fears, and providing alternatives

it challenges the assumptions that knowledge is kept by the elite or the training department

and subverts informal culture by drawing it out.

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In Conclusion…

PBS is based on science and values, and posits Challenging behaviour is functional and meaningful We can view challenging behaviour as communicating something of value We can reduce challenging behaviour by teaching or enabling alternative &

competing behaviours We can reduce challenging behaviour by improving the quality of life of

people We need to support staff to better support people using services Our role as practice leaders includes demonstrating and teach best practice Our role encompasses organising the environment in way that works for

the person.

Tony

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