Positive Behaviour Support

Positive Behaviour Support is a multi-component framework for supporting people with an intellectual disability who may engage in behaviours of concern. In 'Positive Behavioural Support in the UK: A State of the Nation Report', Gore and colleagues (2022) described the key components:

Focus on rights and support to live a good life:

  • Person-centred values and approaches prioritise choice and control
  • Constructional approaches add opportunities to increase skills and independence
  • Partnership working and support for key people
  • Elimination of aversive, restrictive and abusive practices

Understanding behaviour in the context of needs:

  • A biopsychosocial model of behaviours of concern
  • Behavioural approaches to learning
  • Multi-professional approaches

Systematic approach to high quality support:

  • Evidence-informed decision making
  • Creating environments capable of meeting needs
  • Holistic assessment
  • Multi-component personalised support plans
  • Implementation support, monitoring and evaluation

UK NICE guidance (NICE NG11 and NG93) describes tiered support for people with behaviours of concern as follows.

Tier 1 — Universal:

Proactive, whole-setting approaches for everyone

Safe, predictable and engaging environments

Person-centred support

Skilled staff

Promotion of communication, choice, and activity

Tier 2 — Targeted:

Early intervention for people identified as at risk of behaviours of concern

Functional assessment to understand behaviour

Individualised support plans

Skill-building (e.g., coping strategies)

Environmental adaptations

Carer support

Tier 3 — Intensive:

Specialist input for people with severe, high-risk, or enduring behaviours of concern

In-depth functional behaviour assessment

Highly personalised PBS plans

Crisis management strategies

Specialist therapeutic input

Ongoing oversight and review

The benefits of tiered PBS are:

  1. Promotes prevention - Focus on universal and early interventions reduces the need for crisis management and restrictive practices
  2. Matches support to need - Resources and specialist support are targeted where they are most needed, avoiding unnecessary or blanket interventions
  3. Improves quality of life - By addressing the underlying reasons for behaviour, PBS helps people communicate, have more choice and control and meaningfully engage
  4. Reduces behaviours of concern - PBS reduces the frequency, intensity, and impact of behaviours over time through environmental change and strengthening alternative skills
  5. Staff confidence and skills - Improved morale, reduced stress, and safer, more positive environments
  6. Consistency and sustainability - PBS embedded at all levels, from whole-organisation culture to individualised plans, so that good practice is sustained
  7. Meets legal and policy requirements - Aligns with UK NICE guidance, the Restraint Reduction Network Standards, CQC expectations, and the human rights agenda. It helps services demonstrate safe, person-centred care.

When implementing PBS, critical factors for achieving meaningful outcomes are:

  • Skilled and empathic carers
  • Practice leads who coach good practice
  • Organisational structures that support implementation
  • Access to appropriate levels of behavioural expertise

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