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Introduction

Positive behavior support (PBS) is an individualized, research-based process that incorporates the principles of applied behavior analysis and person and family-centered practices to understand what maintains an individual’s challenging behavior.  The overarching goal is to produce lasting changes in the quality of life of the people and to ensure that the support strategies are geared to meeting their goals and overcoming any barriers to an individual’s success (Hieneman, 2015).

The emphasis in PBS is on teaching, rather than just controlling behavior by using the following strategies: modifying aspects of the environment to avoid problems, make difficult circumstances better, or add cues to prompt more adaptive behavior; building skills to help the individual communicate his or her needs, interact with other people, deal with unpleasant circumstances, or become more self-sufficient; and providing consequences that reinforce positive behavior and withhold outcomes that may be desirable to individuals when engaging in problem behavior (Hieneman, 2015).

Theory

The Applied Behavior Analysis (ABA) is used with children and adults with psychological disorders within different settings. ABA therapy main focus is on positively altering particular behaviors, such as skills related to socializing, communicating, adaptive learning, or academics (Sussex, LLC, 2018). ABA’s conceptual foundation is based on a framework of operant learning by Skinner. Dunlap et al (2008) indicated 9 principles that are fundamental to ABA, “the principles of reinforcement, contingency management, stimulus control, shaping, fading, prompting, functional equivalence, generalization, and maintenance”, all laws from behavioral science. A prominent aspect of ABA is having the treatment goals, interventions, and outcomes being socially important and accepted (Dunlap et al., 2008).

Evidence

A study by Lunkenheimer et al. (2008) examined the long-term effects of parents’ positive behavior support (PBS) and children’s school readiness competencies in early childhood. The study hypothesized that children whose parents’ were trained in PBS and regularly supported by behavioral professionals, would develop better language skills and inhibitory control. “High-risk” families (i.e. those with children at risk for behavior problems) at local “Women, Infants, and Children Nutrition” programs from multiple sites were invited to participate in the study with a total of  731 families participating. Each family was assessed each year for 3 consecutive years beginning when the child was 2 years old. Positive behavior support was measured using 4 indicators derived from at-home observations of parent-child interaction during semi-structured tasks. The study revealed that parents in families using PBS and receiving support from behavioral professionals showed improvements in positive behavior support from child age 2 to 3, which in turn promoted children’s inhibitory control and language development from age 3 to 4. The findings also suggest that preventive interventions supporting positive parenting practices, such as PBS, can indirectly facilitate characteristics of school readiness in children at risk.

Case Study

Sarah started showing explosive behavior with her teacher in second grade. Her teacher has noticed that her drawings were often “dark” with depictions of dead and injured people. There was no previous record of any problems. Sarah’s father has bipolar disorder. Additionally, Sarah was exhibiting difficulty controlling her anger; she was acting out- ran out of school, threw an object at another student, and hid in school. At home, she was hurting her younger brother. Sarah was referred for an occupational therapy evaluation due to her problem behavior affecting her academic performance and social functioning. The results of evaluation indicated poor emotional control and low stress tolerance. Additionally, Sarah’s teacher mentioned that she gets very frustrated when presented with difficult tasks and has poor communication skills. After interviewing her mother, it was determined that both of her parents use maladaptive discipline strategies by reinforcing her negative behaviors.

Intervention Plan

Problem Statement

Client presents aggressive behaviors in response to stressful social interactions limiting interactions with peers at school.

Long Term Goals

1. Client will demonstrate safe high quality interactions with peer 5/7 days to promote appropriate social interactions within 4 weeks.
2. Parents will verbally report use of 5 appropriate strategies to manage client’s inappropriate behavior within 4 weeks.

Short Term Goals

1. Parents will incorporate the use of different reinforcement techniques to promote the use of 3 positive behaviors to reduce aggressive behavior in 2 weeks.
2. Parents will verbalize 3 prevention strategies for challenging behavior by next tx session to reduce aggressive behaviors.
3. Client will demonstrate the knowledge of replacement behaviors by identifying 3 positive replacement behaviors to be used in next tx session.

Intervention Format

Individual

Setting

Outpatient

Supplies

None.

Agenda

• Greet Sarah and her family (3 min)
• Review and discuss goals (7 min)
• Orient Sarah and her family to PBS model (5 min)
• Introduce behavioral strategies that would benefit client and her family (5 min)
• Practice the application of strategies (20 min)
• Session reflection and feedback (5 min)

Documentation

S: Sarah’s parents expressed a concern about her aggressive behavior towards her younger brother and peers at school.

O: Sarah and her parents participated in a 45 minute OT session focused on the use of appropriate strategies to manage Sarah’s maladaptive behavior. Sarah was educated on replacement behaviors and instructed to verbally state positive behaviors that were appropriate for use during social interactions. Sarah required mod verbal assistance in carrying out the instructed task. Sarah’s parents were educated on prevention strategies for challenging behaviors and trained to prompt Sarah for appropriate replacement behaviors at home and the use of positive reinforcement to facilitate positive behaviors. Sarah demonstrated insight into the causes of her aggressive behaviors in response to stressful social interactions but poor motivation to change her behavior.

A: Client demonstrated improvement in her understanding and ability to engage in behavior modification strategies. However, client’s poor social skills and low motivation might present a challenge in generalizing these techniques in everyday life. The parental involvement and support in identifying solutions to modifying aspects of environment to avoid problem behaviors, identify triggers, and provide positive reinforcement indicate high potential for helping Sarah communicate her needs, deal with unpleasant circumstances, and become more self-sufficient. Both client and her parents would benefit from skilled OT services to improve the PBS application to correct client’s inappropriate behavior.

P: Sarah and her parents will continue to see OT 2x/week for 45 minutes for 3 additional weeks. Sarah will continue to be monitored for progress in the use of safe high quality interaction with peers.

References

Dunlap, G., Carr, E. G., Horner, R. H., Zarcone, J. R., & Schwartz, I. (2008). Positive Behavior Support and Applied Behavior Analysis: A Familial Alliance. Behavior Modification, 32(5), 682-698.

Hieneman, M. (2015). Positive Behavior Support for Individuals with Behavior Challenges. Behavior Analysis in Practice, 8(1), 101–108. http://doi.org/10.1007/s40617-015-0051-6

Lunkenheimer, E. S., Dishion, T. J., Shaw, D. .S., Connell, A. M., Gardner, F., Wilson, M. N., & Skuban, E. M. (2008). Collateral benefits of the family check-up on early childhood school readiness: Indirect effects of parents’ positive behavior support. Developmental Psychology, 44(6), 1737-1752

Sussex Publishers, LLC. (2018). Applied Behavior Analysis. Retrieved from https://www.psychologytoday.com/us/therapy-types/applied-behavior-analysis