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PBS4’s response to the “Positive Behavioural Support in the UK: A State of the Nation Report” (2022)

 

The original report can be found here: 

https://www.ingentaconnect.com/contentone/bild/ijpbs/2022/00000012/a00101s1/art00001?crawler=true&mimetype=application/pdf 

In 2013 The International Journal of Positive Behavioural Support (BILD) published a definition of PBS. This was intended to be a “line in the sand”, putting straight once and for all what PBS means to a UK audience. However, within a relatively short timescale (9 years) it has been identified that further review of the definition is required. In general, the report is largely welcomed and we support the majority of the content, despite this some of the narrative within the report gives us cause for concern.

There are now 12 standards instead of 10 and, when comparing the new with the old, there isn’t a great deal of variation in the content. On the whole, the two are similar but the language is slightly more accessible, and there is a welcomed increase in focus on rights, person-centred working and involving people. The increase in the number of standards appears to be largely related to breakdown standards further for clarity, this is a positive step forwards. Some of the language remains technical with limited breakdown within the key components e.g. biopsychosocial. This is explained within the main text but our experience from the original definition is that the components alone had a much wider audience reach than the full article. 

The addition of standard 4 is warmly welcomed, this being “Elimination of aversive, restrictive, and abusive practices”. However, can all aversives be removed from life? How many times do we all experience aversives of having to do chores we don’t want to do, or people telling us “no”? Is eliminating all restrictive practices safe, ethical, and enabling for people to have improved quality of life? We work with many people where restrictive practices enable them to live in their own homes in the local community rather than in a secure environment, and restrictive practices may be required to prevent harm from occurring to the person or others. The goal of PBS has always been to negate the need to use “punishment” interventions. These may or may not be aversive or restrictive, and likewise restrictions and aversive approaches may not be punishment. People with learning disabilities will typically, by nature of their disability in learning, have fewer behaviours than us to express their needs and wishes. We have no right to take away behaviours from a person that are functionally effective for them. Instead, we have a duty to support people to increase the behaviours they learn to have more behaviours to effectively meet or communicate their needs. In fact in some situations our goal is to support individuals to develop skills which enable people to tolerate situations that could be considered aversive but are also on occasions unavoidable e.g. sudden routine changes. Whilst point 4 is welcomed, it feels it may be misaligned to what it wants to achieve and we feel a call to eliminate the use of punishment based approaches may have been more evidence based, this starts by supporting others to understand what is a punishment.

We have concerns with the use of the terms “neurotypical” and “neurodivergent” as used in this document and this risk of promoting divisions. There is simply neurodiversity, as we are all a composite of complex neurodevelopmental biological, social, and psychological factors and there is a wide spectrum of neurodiversity. For some their divergence is significant which can affect how they experience the world, or how accessible the world is to them. Those who are usually included when using the term “neurodiversity” include autistic people, people with dyslexia, people with ADHD, people with an acquired brain injury, and people with learning disabilities. On page 7, the report states “PBS as defined here, and in the past, is not intended for persons identifying as neurodivergent who do not have a learning disability.”. This is a very broad statement and is likely aimed to address concerns of autistic campaigners that believe PBS is bad, because they believe ABA is bad. It is a very sweeping statement to say that PBS is not for neurodivergent people who do not have a learning disability. The science of applied behaviour analysis, which PBS is fundamentally based upon, has demonstrated to be a useful approach with various neurodiverse needs. 

The article discusses the fact that autism doesn’t require treatment.  This is a statement we strongly agree with, the phrasing of this indicates that ABA or behavioural approaches do consider “treating” autism. This is concerning and inaccurate. In PBS/ABA, the goal of all intervention is to change socially significant behaviours. Diagnoses or conditions, such as autism, ADHD, or a learning disability, are not targets for intervention. Behaviours that have an impact on the quality of life of the person or those around them, and that are individually valued by them, should be the only targets for intervention.  

We disagree with this statement made on page 9:

“The theoretical underpinnings of PBS are built upon concepts, principles and practices from applied behaviour analysis, but only those that are compatible with PBS core values and aims and that support learning or address behaviours that are likely to cause harm or impact significantly on a person’s life quality in other ways.”

You cannot pick and choose which elements of a science you wish to agree with, a science is a science. This is like saying “We use Maths, but only addition. Subtraction sounds far too negative, and we don’t understand what long division is so don’t acknowledge its existence”! The “Applied” in Applied Behaviour Analysis means that whatever you do in Applied Behaviour Analysis it has to be meaningful and wanted by that person, and we have never come across practitioners that would target self stimulatory behaviours unless the person wanted this or it was having a significant impact upon the persons quality of life. This does not mean it isn’t happening but it should be addressed and challenged in the same way we would any poor and unethical practice would be challenged.

 In contrast to this, later in the report, on page 19, it states 

“Sometimes these practices are described using euphemistic terms as if they are non-aversive (eg, “chill out time” rather than time out or seclusion) or as if they are in the person’s best interests (eg, “natural consequences”). A close technical appreciation and understanding of behavioural approaches in PBS is necessary to identify, challenge and replace such practices as part of PBS implementation”. 

This is said regarding PBS’s role in reducing aversive, or punishing, interventions. It is essential that practitioners have a detailed understanding of the science of behaviour. They must be able to clearly identify all elements of interventions, including punishments and aversives, as many widely used interventions that are not considered as “behavioural approaches” contain aversive elements or punishment. This way, if they are identified they can be monitored and removed quickly and safely. Without this detailed knowledge many punishment interventions we fear are not acknowledged. The paragraph above did not give any explanation as to why these approaches are not recommended but instead said they should not be used, there is a risk this will further increase the use of the “euphemistic terms” as noted above. 

The way to ensure PBS is delivered accurately is professional standards, professional regulation, and clear codes of conduct that practitioners are accountable too. Blurring the line about the importance of the science is not helpful. It feels at times like the report aims to appease autistic campaigners against PBS and please skilled practitioners, but it risks further alienating both.This is further highlighted with the limited focus on skilled, trained practitioners. The report states “no one single profession has a monopoly on the skills needed for delivery of PBS”, whilst we agree with this there must be an emphasis on the need to have a high level understanding and the requirement for qualified individuals to oversee implementation. 

The focus on systems change and a tiered approach is a welcome addition to the definition and article. This is a widely used representation as to how support needs can differ and the intensity of support required for those variable needs. Further explanation as to what the specialist support could look like at Tier 2 and 3 would have been beneficial. There is also a criticism of the lack of research into PBS as a whole but acknowledgement of the research into specific interventions and components. As PBS is a systems approach and a multicomponent framework this is logical as the specific interventions will be individualised, this is consistent with evaluation of other frameworks.  

A final and significant concern is that the overall focus of the report and the updated standards appear to be primarily focussed on the reduction of challenging behaviour. Whilst teaching new skills was mentioned it did not appear prioritised, a primary goal of PBS is to support individuals to develop new skills which as a result will reduce the need for challenging behaviour. By stating it in this order it reduces the focus on preventing behaviour, the article heavily focuses on not using restrictive/aversive practices (rightfully so) but then appears to focus on antecedent management strategies, which often result in removing the antecedent and therefore narrowing someone’s world. It discussed skills teaching as being used routinely, this still sounds like an optional addition whereas this should be a mandatory element of PBS. 

In summary, we recognise with any article covering such a large topic with many stakeholders involved there will be areas in which people do not agree with. As stated originally the definition is generally welcomed and we agree with the majority of the content. That being said, the areas in which we are not in agreement are extremely important and we cannot accept these. We hope this article and our subsequent response opens up the channels of communication to continue to address these areas. 

References

Gore, N.J., McGill, P., Toogood, S., Allen, D., Hughes, J.C., Baker, P., Hastings, R.P., Noone, S.J. and Denne, L.D., 2013. Definition and scope for positive behavioural support. International Journal of Positive Behavioural Support, 3(2), pp.14-23.

Gore, N.J., Sapiets, S.J., Denne, L.D., Hastings, R.P., Toogood, S., MacDonald, A., Baker, P.A., Allen, D., Apanasionok, M.M., Austin, D. and Bowring, D., 2022. Positive Behavioural Support in the UK: A State of the Nation Report. International Journal of Positive Behavioural Support, 12

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