Positive Behaviour Support (PBS) was originally defined in 1990 by Horner et al. It followed decades of the use of a therapy called Applied Behaviour Analysis (ABA), a now hugely controversial form of "therapy" for autistic children and those with learning disabilities. There is often a great deal of confusion between PBS and ABA. This blog aims to explain the difference and Autability's stance on the use of both therapies. To start with though we must explain the basis of Behaviourism.
Behaviourism is a branch of psychology that is very often misunderstood by many, especially when discussed in terms of autism. This particular area of Psychology focuses on observing how changes to an environment affect someone's behaviour. We all learn in a behaviourist way everyday. For example, as a child you may learn that the hob is hot by touching it and feeling pain, therefore you avoid the hob when it is turned on. Having the hob turned on is a change in the environment which changes your behaviour. When it's turned off your behaviour is different as you are automatically not as cautious as you are when it's turned on. In it's raw form, the behaviourist theory shows how we as humans learn how to keep ourselves safe through everyday experiences. When this process is carried out by a person trying to purposefully cause a behaviour through reinforcement rather than by natural consequence in an environment, the term 'conditioning' is used.
Conditioning is a behavioural process. However, it uses a stimulus and response to produce a behaviour from someone that has been purposefully designed to elicit that response. Going back to our example of the hob, the hob is on but is not being used to deliberately hurt anyone. A person learns not to touch it because the natural consequence is to get burnt. In conditioning, a person may introduce or take away an object in order to change behaviour. For example, if an autistic child was stimming whilst holding their favourite toy for comfort, an ABA therapist would remove that toy and refuse to give it back until the child had stopped stimming. The child is conditioned to learn that they will lose their ultimate comfort if they behave in a very normal, and needed, autistic manner. Their behaviour is changed to achieve an outcome that is desirable to other people and the autistic person's needs are not taken into account.
Behaviourism as a theory looks to examine an individual and how they act in different environments. It is not primarily a method of conditioning a person to behave in ways that a group of people see as desirable or 'normal'. However, ABA did involve conditioning and did involve using deterrant actions to change what would now be seen as an autistic person's natural behaviour into one which is desired by the people around them. It is not a therapy that seeks to encourage an autistic child to be themselves, it is in fact the opposite and trains autistic children to become a figure which the world around them desires and tolerates. At Autability we detest ABA and the accompanying theory that changing an autistic person to fit the desires and wants of neurotypical people around them is acceptable. We are anti ABA.
There is one noticeable exception in my personal view. When everyday behaviourism is not enough to teach a child about safety, including autistic children with processing and communication challenges and those with intellectual disabilities, a deterrant method of behavioural learning maybe necessary.
For example, my son still does not understand what the consequences are if he runs out into a busy road. There is no explaining it, his ADHD is too impulsive and he struggles to see consequences for many behaviours. He knows that if he runs out into the road there will be consequences that he would find extremely hard to tolerate. This includes taking his ipad away etc. The safety of a child who has no understanding of safety has to be treated differently in order to keep them safe. You can change many environments for a child such as this, but busy roads, lakes, open water etc. are a certainity on this earth and a child must be prepared for that. In order to avoid ever using the removal of objects as a punishment, I rarely ever take my child near a main road on foot. That is how I change the environment. However he knows if he runs into a road he will lose his ipad and that is the safety deterrant. Many will view this as me changing the way he is and I understand that. However, my primary objective will always be to allow my son to enjoy the world whilst remaining safe. For so many parents, this is a challenge like no other.
So how does Positive Behaviour Support (PBS) differ to ABA? In very simple terms, it is the difference between using aversive behaviour management and non aversive techniques to allow the child to be happy and thrive as themselves. PBS takes the focus off the person's behaviour, and focuses on how the environment and people around them create distress in that person. The child/person is NOT made to change their behaviour. Rather, those who care for them are.
My husband and I have been through PBS once before when Kiddo had very little verbal language and was unable to tell us what was causing distress. We started by picking behaviours he frequently demonstarted that were physically harmful to him and could cause him injury. These are often referred to as 'undesirable behaviours'. I find the term 'undesirable' hugely problematic because it doesn't explain why the behaviour is a problem, it just gives it a negative slant.
Many autistic behaviours are still to this day viewed as undesirable, but that doesn't mean they cause an autistic person any physical harm. The behaviours we chose were purely to reduce his stress levels, allow him to be happier and to keep him safe from serious self injury. Not one behaviour we looked at was a stim. Stims are not physically harmful to him, they calm and regulate him. Some stims can be harmful of course and they would need assessing differently.
Let's take one example of the behaviours we chose. When Kiddo used to (and still does) get distressed, his final behaviour is to bang his head against a hard surface so severely that he can draw blood, cause concussion or other damage. It was a behaviour we had been so desperate to stop, we had even attached memory foam to the walls in his bedroom so he could show his distress without causing himself potentially fatal harm.
We sat down with ALL the people who worked with him on a daily basis. Teachers, school nurses, carers, the lot. If PBS is to be effective everyone MUST follow the same plan. We talked about what type of behaviours Kiddo showed in the hours, minutes and sometimes even days before a severe event of head banging occurred. We had taken diaries beforehand to show any patterns of behaviour linked to events or environments he was in. This moment was monumental for us as a family as for the first time we noticed when his distress was starting to escalate and why.
Using a traffic light system, we drew up a document as follows:
Green - behaviour is happy and relaxed and reflective of his personality with no pressure to be any different. Examples of these behaviours such as humming, smiling and focus.
Amber - certain behaviours were exhibited. For example, putting his hands on his ears, crying, refusing to open his eyes etc. We developed a plan for all adulys working with Kiddo to implement as soon as any of these behaviours were seen. For example, make the environment quite and dark. If this wasn't possible then take him to an environment that was quiet and dark immediately. There must always be one available. If we followed these plans, his distress would reduce and accompanying behaviours would de escalate. He would soon return to green status and would continue his play, work or focus in his new environment.
Red - this was used to describe any behaviour that involved distressed head banging. Essentially, we had not made the changes to his environment quick enough and his distress had escalated.
The aim of the PBS plan was to always avoid the red zone without changing a thing about Kiddo. Since then he has flourished as himself, been more confident around people and in different environments, and most importantly has been so much happier and safer. Any new people he works with are given a copy of the signs to look for and what to do if his behaviour changes. Behaviour is after all, a form of communication.
In short PBS encourages change of environment, not the individual. Yes it is a form of training, but not for the person at the centre of it all. The people who are trained are the parents, carers, professionals. We change our behaviour and the environment so that he can enjoy life as he is meant to.
Time and time again we have heard parents refuse to use boundaries and discipline as a form of behaviour management as it is too similar to ABA.
For children who can understand why the boundaries exist and what the consequences are, they are a must in parenting. Every child needs this if they have the intellectual capability. Behavioural boundaries should never be used to change a neurodivergent behaviour. They should be used when a child makes a conscious and informed decision to cause harm to others through behaviour that is directed at the other person. This means that if a child is self injuring and hurts someone else in the process, it may not be a disciplinary issue. If they have a goal to achieve harm to someone else that is pre meditated and not due to distress due to the environment, it is a disciplinary issue.
Kiddo is no different. As he has got older and undertsands more he is very capable of conducting pre meditated behaviour in order to cause harm to someone else. For example, if someone hits him in the playground (for whatever reason), any attempt to reciprocate that hit and hit them back must be dealt with with discipline on the spot. How are we to know if the other child who hit first was or wasn't in distress at the time? That's not our call, we don't have the knowledge. Sure Kiddo is angry and has every right to be, but we have to show him that acting on anger alone whilst not in distress has consequences.
Children with intellectual disabilities do not always have the mental capacity to pre plan negative behaviour targeted towards someone else when they are NOT in distress. However, what is crucial is being able to spot signs in the environment which may be leading to a build up of stress. A child may act when it seems nothing is wrong, and you may think this is a conscious behaviour to cause harm to someone else. But, have the correct adjustments to the environment been made? Have you been watching for signs of build up of stress? Have you been adapting the environment so that stress naturally lowers for the child? This must be considered before deciding whether a child has acted with intent to cause harm (any kind) when supposedly NOT under environmental stress. Not all signs of distress are outwardly obvious. Many will be internalised and held within. In these cases you may have to keep detailed diaries to work out the sequence of stressors leading to lashing out.
PBS is brilliant, when it's done RIGHT. Make sure you know exactly what is happening. The point of PBS is that children should choose or feel able to change their own behaviour due to a change in environmental circumstances. You become less distressed when you're in an environment you feel safe in. Neurodivergent people should NEVER be forced to change their behaviour due to environmental circumstances. They should NEVER be foreced to change their behaviour to suit other people if their behaviour is not causing anyone any harm.
The final thing to note is that some days, environmental changes aren't enough. Your child could be ill, or have intellectual disabilities, and this may mean that some days preventing the red zone just isn't possible. Once your child is in the red zone, don't expect to be able to reverse a meltdown or intense distress. PBS is about preventing that stage, not reversing it. Sometimes all you can do is keep your child safe and be there for them until the distress passes.
PBS is positive, if you make it so.
Please note: seek specialist advice when using PBS for a child with intellectual disabilities.