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Executive
Summary
This
executive summary was written by AIR personnel and reflects the
work of the following research report.
Positive
Behavior Support as an Approach for Dealing with Problem Behavior
in People with Developmental Disabilities: A Research Synthesis
Authors: Edward G. Carr, State University
of New York at Stony Brook, Robert H. Horner, University
of Oregon, Ann P. Turnbull, University of Kansas, Janet
G. Marquis, University of Kansas, Darlene Magito-McLaughlin,
State University of New York at Stony Brook, Michelle L.
McAtee, State University of New York at Stony Brook, Christopher
E. Smith, State University of New York at Stony Brook, Kaarin
Anderson Ryan, State University of New York at Stony Brook,
Michael B. Ruef, University of Kansas, Ajit Doolabh, State
University of New York at Stony Brook
Background
and Purpose
Problem
behaviors (aggression, self-injury, tantrums, property destruction,
etc.) have long been barriers to successful education, socialization,
employment, and community adaptation. Positive behavior support
(PBS) involves applying behavioral principles within community
norms to reduce problem behaviors and build appropriate behaviors
that result in durable behavioral changes and, just as important,
an improved lifestyle. The key to PBS is that, to remedy problem
behavior, it is necessary first to remedy deficient contexts.
There
are two kinds of deficient contexts: environmental conditions
and behavior repertoires. Deficient environmental conditions include
lack of choice, inadequate teaching strategies, poorly selected
daily routines, among others. Deficient behavior repertoires include
inadequate or absent skills in communication, self-management,
socialization, and other functional skills. There has been much
recent discussion of the strong association between these two
types of deficiencies, leading to the conclusion that problem
behavior can be effectively addressed by focusing on the assessment
and remedying of context.
Since
all strategies for remedying deficient environmental conditions
involve manipulating stimuli (e.g., curriculum materials and daily
living routines), they are referred to as stimulus-based
interventions. Likewise, since all strategies for improving
deficient behavior repertoires involve a systematic and targeted
application of reinforcement, they are referred to as reinforcement-based
interventions.
The
purpose of this report is to synthesize the research on PBS between
1985 and 1996. The research synthesis provides an analysis of
the existing PBS research database (109 published articles, with
data on 230 participants, met the criteria for inclusion); compares
that database with current clinical needs in the field; and suggests
future directions for research, practice, and policy. The focus
is on the application of behavior support for people with developmental
disabilities and autism from early childhood to adulthood.
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Findings
There
were five research questions posed as the core of this review
of the literature on PBS research. Those questions, and the key
findings associated with each, follow.
How
widely applicable is PBS?
-
The
approach is widely applicable to people with serious disabilities
(e.g., mental retardation and autism) who exhibit serious behavior
problems (e.g., aggression and self-injury) as well as those
with mild to moderate disabilities.
- The
approach can be applied by typical intervention agents (those
persons who would normally be the primary support people or caregivers
in a community, such as parents, teachers, and job coaches) in
typical settings (homes, community, and integrated schools). Its
use is not restricted to involvement of highly trained professionals,
such as psychologists and researchers (atypical intervention agents),
even though that is often still the case.
In
what ways is the field evolving?
-
PBS
is not merely a passing fad. It has been showing steady and
dramatic growth, especially during the 12-year period reviewed.
-
Outcomes
involving the most difficult problem behavior (e.g., self-injury
and multiple problem behaviors) have become more numerous.
-
Generally,
typical and atypical intervention agents are about equally likely
to conduct PBS intervention. Also, although atypical intervention
settings (e.g., segregated schools and medical clinics) are
more likely to be the venue for intervention, the trend toward
the use of typical settings is on the upswing.
-
There
has been a dramatic upward trend in the use of assessment prior
to planning intervention.
-
Both
formal functional analysis and informal behavioral assessments
have become more numerous.
-
There
is an increasing focus on escape-motivated problem behavior
as well as on problem behaviors with multiple motivations.
- Repeated
assessments have remained uncommon; however, when they do occur,
they are more likely to be carried out by typical intervention
agents in typical settings.
-
Stimulus-based
intervention has gradually become more common than reinforcement-based
intervention.
-
Combination
interventions do not show an increasing trend; however, when
they do occur, they are more likely to be carried out by typical
intervention agents in typical settings.
-
With
respect to systems change, significant others (parents, teachers,
job coaches, etc.) are increasingly likely to alter their behavior
as part of the intervention. No trend is seen, however, for
environmental reorganization, a critical aspect of systems change.
-
Intervention
in all relevant contexts does not show a trend; however, when
it does occur, it is most likely to be done by typical intervention
agents in typical settings.
-
There
is an upward trend in outcomes associated with short-term maintenance
(five months or less) but none for longer-term maintenance.
- Outcomes
associated with generalization (the degree to which intervention
effects transfer to other situations), lifelong change, and social
validity (determined by parents, teachers, and job coaches) show
no trends and are few.
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How
effective is PBS?
-
Modest
to substantial increases in positive behavior are typically
observed following the application of PBS intervention.
-
With
respect to reduction in problem behavior, about one-half to
two-thirds of the outcomes are successes (using a criterion
of 90 percent or more versus 80 percent or more decrease, respectively,
in problem behavior from baseline).
-
Typically,
the success rate does not change as a function of whether stimulus-based
intervention and reinforcement-based intervention are used alone
or in combination with one another, nor does it change when
non-PBS interventions are added.
-
With
respect to the degree that intervention effects were documented
to last over time (maintenance), about two-thirds of the outcomes
are successes (using a 90 percent reduction criterion). However,
the database is small and gets smaller as the duration of follow-up
is lengthened.
-
There
are demonstrations of successful lifestyle change and good social
validity (where parents, teachers, and job coaches perceive
the intervention and its effects to be worthwhile). However,
these data are reported only for a small minority of outcomes.
-
PBS
works just as effectively with individuals with multiple disabilities
as compared to those with a single disability.
- PBS
is just as effective for individuals with complex disabilities
as compared to those with less complicated disabilities.
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What
factors modulate the effectiveness of PBS?
-
Intervention
for combinations of problem behavior produces lower success
rates than intervention for single types of problem behavior.
-
The
success rate (using a 90 percent reduction criterion) for interventions
based on a prior functional
assessment was almost twice that obtained for when this
type of assessment was not conducted.
-
The
success rate (90 percent criterion) was greater following interventions
that involved systems change such as environmental reorganization
and change in the behavior of those typically involved with
the individual with a disability.
- The
success rate (90 percent criterion) associated with those typically
involved with the individual with a disability was higher than
that obtained with those who do not have ongoing relations with
the individual.
How
responsive is the PBS literature to the needs of consumers (nonresearchers)?
-
Comprehensive
lifetime support is a major goal of families, but the database
rarely addressed this issue.
-
Families
are most concerned with long-term behavior change. The database,
in a minority of cases, demonstrated such change. However, no
outcomes involved follow-up of longer than two years, whereas
most families think of maintenance in terms of decades rather
than months.
-
Consumers
(e.g., parents and teachers) judge interventions in terms of
their practicality and relevance, and are concerned with how
well intervention plans mesh with the realities of the complex
social systems in which the consumers must function.
- Consumers
are concerned with obtaining support for themselves in addition
to support for people with disabilities. This topic was not a
focus of systematic research in the studies included in the database.
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Recommendations
Below
are brief recommendations for advancing the field of PBS, looking
at the areas of research priorities, service provision, social
policy, and government action.
Researchers:
Researchers
need a new applied science. For a truly applied science to develop,
researchers should address consumer needs more systematically
and frequently. A robust applied science will require changes
in assessment and intervention practices, a redefinition of what
constitutes a significant outcome, and measurement procedures
that address these new priorities.
Service
providers:
Service
providers must fix problem contexts, not problem behavior. That
is, whenever problem behavior is identified as a clinical issue,
service providers should structure intervention to reflect a knowledge
(from systematic assessment) of what is wrong with the individual's
environment and skill repertoire. Then, redesigning the environment
and enhancing the individual's adaptive skill repertoire will
strengthen positive behavior while decreasing problem behavior.
Social
policy:
Regulations
that define quality of services need to mandate standards of best
practice. These standards include repeated functional
assessment that identify the environmental and behavioral
deficiencies; linkage between functional assessments and the design
of interventions; consideration of the long-term perspectives
of consumers; and definition of outcome goals in terms of comprehensive
lifestyle change and support, not just reduction of problem behavior.
Government:
Resources
should be invested to ensure the continued development and evaluation
of a truly applied science of PBS that is sensitive to consumer
needs. Also, government can develop grant competitions, create
a nationally accessible database on PBS, and convene periodic
conferences on PBS.
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