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Positive behaviour support: What model of disability does it represent?

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DOI: 10.3109/13668250.2016.1164304

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Positive behaviour support: What model of

disability does it represent?

Ian Grey, Helena Lydon & Olive Healy

To cite this article: Ian Grey, Helena Lydon & Olive Healy (2016): Positive behaviour support:
What model of disability does it represent?, Journal of Intellectual and Developmental
Disability, DOI: 10.3109/13668250.2016.1164304

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 JOURNAL OF INTELLECTUAL & DEVELOPMENTAL DISABILITY, 2016
http://dx.doi.org/10.3109/13668250.2016.1164304

CONCEPTUAL PAPER

Positive behaviour support: What model of disability does it represent?

Ian Greya, Helena Lydonb and Olive Healya
a
School of Psychology, Trinity College, Dublin, Ireland; bDepartment of Psychology, National University of Ireland Galway, Galway, Ireland

ABSTRACT KEYWORDS
Positive behaviour support (PBS) has become well established as an intervention approach for positive behaviour support;
individuals with intellectual disability and challenging behaviour. However, what remains models of disability;
Downloaded by [National University of Ireland - Galway], [Helena Lydon] at 01:48 01 April 2016

unexplored is the relationship between PBS and the medical and social models of disability, challenging behaviour
which historically are the dominant conceptual frameworks put forward in understanding
disability. This paper identifies the difficulties in exploring this relationship due to the often
simplistic portrayals of such models. Though PBS has a change agenda, typically a characteristic
of the medical model, it is change at an ecological level that is central to PBS. An analysis of the
practices of PBS demonstrates a concern with pragmatically identifying the interaction between
person and environment to reduce the occurrence of challenging behaviour. PBS practices are
considered to be more aligned with a supports model because they build an individual ecology
of support tied to meaningful quality of life outcomes for individuals with challenging behaviour.

Introduction position of PBS as an approach in the context of existing

In the past 20 years, positive behaviour support (PBS)
has become well established in intellectual disability ser-
vices in many countries, including the United States, the
United Kingdom, Australia, and Ireland. Its establish-
ment is not merely reflected in an uptake in the practices
that characterise PBS; in some countries, statutory legis-
lation for PBS has also been introduced. Perhaps the
most recent example of this has been in the Republic
of Ireland, where PBS is now mandated, in instances
where both children and adults with a disability in resi-
dential and respite centres display challenging behaviour
(Department of Health, 2013). The factors associated
with the increasing presence of PBS in disability services
are a direct result of its efficacy as an approach in redu-
cing both the frequency and severity of challenging
behaviour displayed by individuals with intellectual dis-
ability, but also because it resonates strongly with the
values underpinning modern service provision. Fore-
most among these values is the primacy of increasing
quality of life, the importance of social role valorisation
(Kunc, 1992; Wolfensberger & Tullman, 1982), and a
nonaversive approach to intervention for challenging
behaviour. Although the application of behavioural tech-
nology lies at the centre of PBS, several authors have
expertly argued that there is nothing inherent in these
values that require the rejection of behavioural technol-
ogy (e.g., LaVigna & Willis, 1996). However, what has
generally been absent to date is an examination of the
models of disability such as the medical and social
model.
The literature makes reference to a variety of models
that have been developed in order to reflect the complex-
ity and comprehensiveness of disability. These models
attempt in various ways to describe the complex inter-
play between a variety of variables such as economic sys-
tems, legislation, concepts of normality, education, the
construction and delivery of services, and societal atti-
tudes. In particular, these models attempt to capture
the impact of this complex interplay for somebody
with a disability. Although such models are simplified
abstract views of complex realities, they are nonetheless
useful heuristics with which to identify patterns in both
current and past practices, and to identify the lived
implications for someone with a disability. Frequently,
the categorisation of both the practices and character-
istics of intervention approaches associated with disabil-
ity services has taken place in the context of what have
been termed the medical and social models of disability
(Oliver, 1990). However, identifying which model PBS
resonates most with is difficult owing to sometimes con-
flicting attributions made in respect of each model.
Given the surge in popularity of PBS practices in many
countries, it is an opportune time to identify what fea-
tures it has in common with these models and to deter-
mine whether it in fact represents a different model and

CONTACT Ian Grey ian.grey@zu.ac.ae

© 2016 Australasian Society for Intellectual Disability, Inc.
 2 I. GREY ET AL.
whether it brings with it advantages for those with intel-
lectual disability and challenging behaviour.
Positive behaviour support
Since its origins in the 1980s, PBS has become increas-
ingly dominant as a major approach in which both ser-
vices and policymakers address challenging behaviour
displayed by individuals with intellectual disability and
autism spectrum disorder (ASD). Although there have
been some variations as to what the defining features
of PBS are, the definition by Carr et al. (2002) is adopted
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here: “PBS is an intervention technology based on social,
behavioral, educational, and biomedical science that
combines evidence-based practices with formal systems
change strategies focused on both improving the valued
lifestyle options available for an individual and reducing
problem behaviors” (Dunlap, Carr, Horner, Zarcone, &
Schwartz, 2008, p. 684). More recently, Dunlap, Sailor,
Horner, and Sugai (2009) have identified four core fea-
tures of PBS: (a) application of research-validated behav-
ioural science; (b) integration of multiple intervention
elements to provide ecologically valid, practical support;
(c) commitment to substantive, durable lifestyle out-
comes; and (d) implementation of support within organ-
isational systems that facilitate sustained effects. Central
to both definitions is the application of behavioural
science, the goal of improving quality of life and the
need for systems change.
PBS originated from the merger of a number of devel-
opments and policy changes in the 1980s such as deinsti-
tutionalisation in a number of countries, the rise of the
disability rights movement, social role valorisation, and
the delineation of a set of values that should underpin
service delivery for people with intellectual disability
and challenging behaviour. The first of these values
was that people displaying challenging behaviour should
not be exposed to aversive procedures designed to reduce
such behaviour (Donnellan, LaVigna, Negri-Shoultz, &
Fassbender, 1988). The second was that intervention
should not have a solitary focus on behaviour reduction
but should aim to provide meaningful and socially valid
lifestyle outcomes. To this end, desired outcomes in PBS
from the outset were to include developing and main-
taining satisfying relationships, participating in pro-
ductive and meaningful employment or educational
opportunities, participating in desired recreational
activities, and developing the skills necessary to function
effectively in the community (Anderson & Freeman,
2000).
A primary goal of PBS is to apply empirically vali-
dated interventions in order to reduce problem beha-
viours and build appropriate behaviours that result in
durable change and lifestyle change for the person. To
achieve this, PBS primarily relies on the methodologies
and procedures embedded in the science of applied
behaviour analysis (ABA). However, beyond utilising
assessment and intervention methodology derived from
the principles of ABA, it also shares some of the core fea-
tures of the science with a dedication to empiricism,
research methodology, a focus on pragmatism and uti-
lity, and a solid conceptual foundation in operant psy-
chology (see Dunlap et al., 2008). In addition, it places
considerable emphasis on macro-variables to include liv-
ing arrangements, educational placements and interper-
sonal relationships, and quality of life (McClean & Grey,
2007). Although ABA has a stated commitment to social
validity since its inception (Baer, Wolf, & Risley, 1968),
relatively little of the traditional behaviour analytic
research base that has accumulated since that time has
addressed issues such as this. PBS also brings with it sys-
tems of person-centred planning and an emphasis on
broader systems change through a focus on the sociology
of behaviour that emphasises organisational and cultural
systems within which support is provided (Horner et al.,
2005). The emphasis on systems such as person-centred
planning and team-based decision-making extends
behaviour support beyond immediate manipulation of
events to an overt recognition that schedules, staffing
patterns, cultural expectations, physical conditions, bud-
geting, and organisational policy are also likely to affect
the success of support systems for people with intellec-
tual disability (Horner et al., 2005).
As such, PBS may be best thought of as a framework
for developing effective multicomponent interventions
for individuals who display challenging behaviours
(Wacker & Berg, 2002). Services consistent with a PBS
framework generally share a number of characteristics,
including operating from a genuine person-centred
values base, recognising and responding to the indivi-
duality of each person, working to achieve meaningful
personal outcomes, such as increased quality of life,
and using empirically supported assessment and inter-
vention strategies drawn from the science of ABA. To
date, research into PBS has demonstrated that it is effec-
tive in reducing the frequency and severity of challenging
behaviour (Grey & McClean, 2007; McClean et al., 2005)
and is effective at achieving its goal of improving quality
of life (Carr et al., 1999; McClean, Grey, & McCracken,
2007).
The medical model
In the field of disability studies, the medical model has
been much maligned, and it can be argued that represen-
tations or depictions of this model have been characterised

by a degree of stereotyping. Traditional depictions of the
medical model tend to portray it has having a number of
negative characteristics and implications for individuals
with disability, such as (a) it locates the problem of disabil-
ity solely within the individual with undesirable conse-
quences such as the experience of stigma, (b) the causes
of disability stem directly from health conditions including
psychological losses, and (c) medical intervention is seen as
the first appropriate response. However, it has been put
forward for over a decade that descriptions of medical per-
spectives of disability have become more multidimensional
than those in earlier years (Williams, 2001). For instance,
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Frontera (2006) has argued that an individual “depends on
having biological, physical and psychological integrity to
perform activities and disruption to any of these can
bring about impairment and functional loss in activities”
(p. 1068). Frontera’s description of the medical model pro-
vides an acknowledgement that although disability may be
a final outcome, it is, however, not defined by the biology
of disease or injury but by the interaction between biology
and the environment surrounding the person as well as the
demands of the social and occupational activities of the
person (Frontera, 2006). Such a perspective within the
medical model has led to the emergence and establishment
of rehabilitative medicine and in particular the important
role of assistive technology (O’Reilly et al., 2014). Such
technology is viewed as being able to “replace biological
or mental functions and at least partially restore activity
and participation” (Frontera, 2006, p. 1069). This view
reflects a complex interplay between environment and
biology and can also to be seen in contemporary descrip-
tions of public health models of medicine. These descrip-
tions are explicitly ecological in nature in so far as that they
clearly articulate that “health and well-being are affected by
an interaction among multiple determinants including
biology, behaviour and the environment” (Gebbie, Rosen-
stock, & Hernandez, 2003, p. 21).
The foregoing discussion highlights a disparity in the
typical portrayal of the medical model in the disability lit-
erature, with the latter descriptions reflecting a more
dynamic interplay between person and environment and
even the role that may be played by assistive technology
in overcoming or dealing with disability. To overcome
this disparity, it may be tempting to recontextualise the
medical model, as it is frequently described in the litera-
ture as indicative of a mode or type of thinking about dis-
ability more characteristic of a particular period in history
(e.g., early 20th century). However, the wide variation in
approaches to service provision throughout the world
suggests that this type of thinking is not simply a historical
event lying in the past but one that is still active and quite
dominant in some parts of the world today (Grey, Al-Sai-
hati, Al-Haddad, & McClean, 2015). Furthermore,
JOURNAL OF INTELLECTUAL AND DEVELOPMENTAL DISABILITY 3
because the medical model is frequently discredited in
the field of disability studies, its advantages are sometimes
overlooked. In certain cases, interventions drawn from a
medical model approach may be considered appropriate
for specific people with disability. For example, a child
with a primary disability of cerebral palsy will benefit
from physical therapy and will experience a decrease in
the physical challenges experienced at subsequent devel-
opmental stages as a result of such intervention. By choos-
ing an intervention that lessens the impact of a child’s
disability, the capacities and potential outcomes for the
child or adult to engage in activities have been enhanced
(Bricout, Porterfield, Tracey, & Howard, 2004).
The difficulty that arises with the medical model is
that, historically at least, it excluded contextual factors
resulting in a sole focus on the impairment or deficit
itself. In this sense, the medical model approach is
unsuited to understanding person–environment inter-
actions and how such interactions result in the experi-
ence of disability. However, some writers classify
certain practices as associated with the medical model,
which is surprising. For instance, Juno (2007) states
that the medical model defines disability “as a physical
and intellectual condition where change could be
brought around through medical or educational inter-
ventions” (p. 80). This statement reflects three crucial
issues that continue to play out in the literature. First,
it indicates that a change agenda targeted at the individ-
ual is at the heart of a medical model and, second, that
educational interventions in the service of a change
agenda are also part of the medical model. Finally, it
raises the question of the involvement of medical, edu-
cational, and indeed other professionals with people
with disability. For example, some have called for the
rejection of the involvement of professionals with indi-
viduals with disability because such relationships
between therapist and child or adult create a dependency
culture (Waltz, 2013). It has also been argued by some
that only cosmetic changes have taken place in this
arena and that professionals are just as trapped as the
person with a disability themselves (Lang, 2007). Lang
goes so far as to argue that “the dominant hegemony
of individualism, the medicalisation and categorisation
of disability, and the resultant dependency of disabled
people will remain unaltered” (p. 14).
The key issue appears to be that both explicit and
implicit attempts at cure or even normalising the person
with a disability are at the heart of a medical model and
its associated system of supports. These associated sys-
tems of support include the typically available pro-
fessional groups normally seen in multidisciplinary
teams. For example, Waltz (2013) categorises physical
therapy, occupational therapy, sensory integration, and
 4 I. GREY ET AL.
speech therapy as “quasi-medical services.” Such a
description categorises the majority of intervention
approaches as characteristic of the medical model and
often with an implicit message that as such they should
be rejected because they focus on impairment and con-
tribute to a culture of dependency.
The social model
There is one core defining feature associated with the
social model, which is the distinction between impair-
ment and disablement. The majority of descriptions of
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the social model of disability have this distinction as a
core pivot point and which go back to the earliest con-
ceptualisations of the model (Oliver, 1990). One clear
result of the social model of disability is that it separates
impairment (the individual effect of loss or lack of a limb,
function, or mechanism of the body) from disability. The
disability rights movement has defined this distinction as
a disadvantage resulting in restriction or oppression of
people with impairments caused by physical and insti-
tutional barriers to result in social exclusion and stigma.
The premise therefore associated with the social model
definition of disability is that difficulties arise from “the
disadvantage or restriction of activity caused by a con-
temporary social organisation which takes no account
of people who have physical impairments and learning
difficulties and thus excludes them from mainstream
social activities” (Llewellyn & Hogan, 2000, p. 160). In
this argument, impairment becomes disablement when
various barriers are imposed on the person, which fail
to take account of the impairment. In effect, these bar-
riers serve to propel impairment into the realm of dis-
ability. The distinction between the concepts of
“impairment” and “barrier” was indeed a profound
insight and one that has over the past 20 years heralded
a raft of positive changes in both legislation and critical
thinking about the nature of “service.” The kernel of
the distinction was that although impairment may be a
given, it is the presence of barriers that give rise to dis-
ablement. This in itself has had some profoundly positive
implications in that the appropriate environmental
adaptations required for people with disability to partici-
pate fully in society were subsequently recast as rights.
The social model can be contrasted with traditional
ways of understanding disability (i.e., the traditional
medical model), which locates the problem of disability
in the impaired individual, and views the difficulties
experienced by the individual as the direct and inevitable
consequences of impairment. Oliver (1990) has
described this as personal tragedy theory, which brings
with it a medical model system of response. In this theor-
etical framework, people with disability are perceived as
requiring a plethora of supports to enable them to come
to terms with their impairments. In addition, there may
be a belief within this theoretical lens that they require
some form of cure and participation within a society
without disability. It has been argued that great efforts
have been put into dividing people with disability from
each other as they are channelled into segregated services
aimed at specific impairments (Chappell, Goodley, &
Lawthom, 2001).
One of the influences of the social model can be seen
in the International Classification of Functioning, Dis-
ability and Health (World Health Organization, 2001),
which produced a synthesis of biological, psychological,
social, and environmental concepts to provide a more
comprehensive understanding of disability. Disability
could now be understood as an experience that occurs
in a context and as the result of three mutually interact-
ing levels: the body, at the level of activities, and at the
level of participation in society (Kostanjsek et al.,
2011). In summary, it put forward a biopsychosocial
model for understanding disability and one where dis-
ability should be considered as essentially occurring
within the context of environmental and personal fac-
tors. This approach first and foremost reflects an interac-
tionist perspective on disability in that impairment
interacts with environment to result in disablement.
However, within the social model, as defined by some
at least, there appears to be a somewhat uneasy alliance
with the involvement of professional groups (e.g., thera-
pists) and consequently the implementation of interven-
tions associated with professionals for people with
disability. Some have argued that a social model perspec-
tive is not a denial of appropriate individually based
interventions, but, whether they are remedial or edu-
cational, the issue put forward by others is that they
may be limited in terms of furthering the empowerment
of people with disability (Barnes, 2010). According to
Oliver (2007), the primary implication of the social
model involves a switch away from focusing on the limit-
ations of particular individuals to the way the physical
and social environment impose limitations on certain
categories of people. Intervention approaches not foster-
ing such a switch may be rejected by such an interpret-
ation of the social model. Well intentioned, as such
services may be, it would seem that if they are in the ser-
vice of altering impairment then they are more readily
identifiable as belonging to the medical model. Further-
more, owing to the essentially rehabilitative nature of the
work of these professionals, attempts at cure or rehabili-
tation may be considered discriminatory if against the
wishes of the parent or the person themselves, and that
this attitude of changing the person can harm self-esteem
and even militate against social inclusion. Some have

gone so far as to claim that those seeking the involve-
ment of professionals may do so as a result of some
pathological process taking place. Waltz (2013), for
example, has argued that “approaches that claim scienti-
fic backing have great appeal to parents [of children with
autism] because the parents’ social identity has been sys-
tematically devalued as they gain confidence and power
by association” (p. 125). Such parental denigration, how-
ever, risks losing the genuine and real insights associated
with the social model and also seems to suggest that
science is the enemy of the social model.
One interpretation of the social model emphasises the
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recasting of disability by people with disability and the
importance of collective action. As a result, calls are
made for the individual and collective responsibility of
all societal members to dismantle disablement, and pro-
mote a socially aware, active, and inclusive culture.
Within this perspective, individuals with disability are
an oppressed group as the result of a stigmatising social
world. A frequent corollary of this argument is that
attempts at intervention are further stigmatising and
what is needed is intervention at a much broader social
level to bring about acceptance. This argument is cur-
rently playing out in the field of ASD, where some
have called for an acceptance of neurodiversity and a
rejection of a change agenda in respect of the core fea-
tures of ASD (Waltz, 2013). We believe this to be a sim-
plistic argument, however, as a genuine acceptance of
neurodiversity is not inimical to a change agenda for
three reasons. First, the environments of individuals
with ASD who display challenging behaviour frequently
need to change so that the person can grow and reach
their potential (McClean & Grey, 2012). Second, accep-
tance does not preclude the need for change and this is
a fundamental dialectic of therapeutic approaches in
general. Third, acceptance and intervention are not
mutually exclusive positions. For example, acceptance
of having a medical diagnosis of cancer does not pre-
clude its medical treatment.
However, a frequent oversight often involves an
articulation of the social model of disability in relation
to those individuals with sensory and physical impair-
ments (see, for example, Oliver, 2007). Individuals with
intellectual disability and such co-occurring difficulties
typically have been viewed as presenting with problems
that are intrinsic to the impairment rather than the result
of a disabling environment (Chappell et al., 2001). In
contrast, Goodley (2001) has claimed that an extensive
body of research over 30 years has demonstrated that
intellectual disability is a social creation of a disabling
society. With respect to challenging behaviour he goes
on to state that “ideologically, such behaviour is seen
as reflecting some underlying (‘organic’) individual
JOURNAL OF INTELLECTUAL AND DEVELOPMENTAL DISABILITY 5
deficiency, and these assumptions permit or sanction
professional discourse and practice” (Goodley, 2001,
p. 213). This perspective is of course completely at
odds with a PBS perspective, which emphasises problem
contexts as a predominant casual factor in the origin and
maintenance of challenging behaviour. However, Good-
ley’s (2001) argument that “we should not lose sight of
how environments shape, define and create (views) of
behaviour that are so often misread as correlates of
‘embodied impairment’” (p. 213) is a valid one in our
view. Despite this, the social model may be of little prac-
tical use as a framework to understand challenging
behaviour. This is partly because it identifies sociological
processes and macro-psychological process (e.g., societal
attitudes) as a broad entity requiring change but falls
short on the issue of pragmatism as to how such pro-
cesses can be effectively changed around the individual
person. The model fails to identify the frequent idiosyn-
cratic changes or adaptations that need to be made for
the individual with intellectual disability and challenging
behaviour.
The supports model
As stated earlier, some writers on the social model have
called for collective social action to overcome the barriers
that give rise to disability. Although laudable, the chal-
lenge is how to achieve collective action on such a
scale and whether this can result in societal changes par-
ticularly for individuals with intellectual disability and
co-occurring challenging behaviour. Llewellyn and
Hogan (2000) have put forward the need for a transac-
tional understanding of disability, one they claim goes
beyond the social model and one that can produce
change at the level of the individual. They argue that a
transactional perspective of disability enables us to
examine the way in which disability is not only created
and maintained by nonsupportive environments, but is
also caused and sustained by problematic social relation-
ships. Their transactional model of disability proposes
that challenging behaviours do not have single or linear
causes and draws attention to the “large number of vari-
ables interacting and, indeed, multiplying their effects as
a result of the interactions taking place” (Llewellyn &
Hogan, 2000, p. 162). Such a perspective would appear
to offer a conceptual approach to expanding beyond
the social model to the level of the individual by examin-
ing the interaction between the person and their own
idiosyncratic environment. However, the transactional
model is mentioned infrequently in reviews of models
of disability since its original publication. This is most
likely attributable to the fact that such a perspective on
the dynamic interplay between the person and their
 6 I. GREY ET AL.
own environment had already firmly established itself in
what is known as the supports model of disability (Luck-
asson et al., 2002).
The changes that occurred in the 1980s, including
deinstitutionalisation in a number of countries, normal-
isation, the rise of the disability rights movement, and
the articulation of social role valorisation, had a signifi-
cant impact on the reconceptualisation of disability.
One additional key development at this time, however,
was the recognition that positive outcomes for people
with intellectual disability was related to one key issue:
that of achieving congruence or “fit” between the per-
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son’s own specific behavioural capacity and the capa-
bility of their own specific environment to promote
growth and development (Buntinx & Schalock, 2010).
The key premise is that the environment of the person
could be arranged in a manner analogous to that of a
prosthesis in that the application of appropriate tailored
supports could improve functional capabilities and result
in enhancing dependence and interdependence. This
orientation towards congruence reflected a growing rec-
ognition of the critical reciprocal and dynamic relation-
ship between behaviour and environment. Although this
theme is apparent in the transactional model, the sup-
ports model expanded substantially on this insight and
provided three key concepts revolving around the issue
of support for individuals with intellectual disability:
support needs, supports, and system of supports (Bun-
tinx & Schalock, 2010). First, support needs are defined
as the specific pattern and intensity of supports necessary
for a person to participate in a range of normative activi-
ties ranging from domestic to community to social.
Second, supports are defined as the “resources and strat-
egies that aim to promote the development, education,
interests, and personal well-being of an individual and
that enhance human functioning” (Buntinx & Schalock,
2010, p. 288). Third, the system of supports is defined as
the planned and systematic use of individualised support
strategies and resources that result in meeting the real
interests of the person and which result in improved wel-
fare for the individual.
The impact of a supports model with its focus on the
close interplay between the person and their immediate
ecology is evidenced in several developments. First, the
pattern of assessed needs and required supports rather
than the category of disability or the deficits the person
exhibits has become the basis for planning services in
education, residential, and other services in several
countries. Second, the amount or intensity of supports
needed by a person has in many countries formed the
basis for funding or resource allocation rather than cat-
egory or severity of disability the person may have.
Third, the supports model has provided a context for
the integration of related practices such as person-
centred planning, social role valorisation, and empower-
ment (Buntinx & Schalock, 2010). One of the key issues
confronting a supports model is the accurate and com-
prehensive assessment of actual needs and the provision
of effective supports. This is critical and the goal of a sup-
ports model is to provide the correct natural and paid
resources to have more satisfying and fulfilling lives.
Where does PBS sit?
From the foregoing discussion of the medical, social, and
supports models, five core issues arise when attempting
to answer the question of where PBS sits on the tra-
ditional medical–social model distinction:
(1) Does it attempt to classify and normalise
impairment?
(2) Does it subscribe to a dynamic interaction supports
model of disability?
(3) What is its conceptual approach to challenging
behaviour?
(4) Is it a quasi-medical intervention system?
(5) To what extent does it reflect an emphasis on pro-
fessional involvement with the person with co-
occurring challenging behaviour?
It is worth being reminded at this point that PBS is an
approach for reducing challenging behaviour, which
itself reflects a definition embedded in a social model as
culturally abnormal behaviour(s) of such an intensity,
frequency or duration that the physical safety of the per-
son or others is likely to be placed in serious jeopardy, or
behaviour which is likely to seriously limit use of, or
result in the person being denied access to, ordinary
community facilities. (Emerson, 2001, p. 3)
This particular definition of challenging behaviour has
subsequently been expanded by McVilly (2002) to
denote any behaviour that
(1) is a barrier to a person participating in and contri-
buting to their community (including both active and
passive behaviours); (2) undermines directly or
indirectly a person’s rights, dignity or quality of life;
and (3) poses a risk to the health and safety of a person
and those with whom they live and work. (p. 7)
This expansion is important as it identifies challenging
behaviour as first and foremost a barrier, and it is of
course barriers that result in disablement within the
social model. Within a PBS approach there is no attempt
to normalise the person but there is a clear agenda of
providing normative valued experiences, and identifying
the barriers that prohibit such experiences from

occurring, as a result of environmental or skills deficits.
This aspect of PBS is almost parallel with depictions of
a social model, which emphasises that disability is the
outcome of interactions between people and their
environments. In PBS, challenging behaviour is also
viewed as the result of such interactions; that is, it is
learned behaviour that has functional outcomes for the
individual. One feature of PBS that is sometimes over-
looked in the literature is that functional assessment pro-
cedures employed to determine purposes of challenging
behaviour are only a constituent part of a thorough com-
prehensive behavioural assessment. Such comprehensive
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assessments are and should be integral to the assessment
process in that they serve a number of key functions, but
foremost among these is a full biopsychosocial assess-
ment for the person concerned. This typically includes
assessment of cognitive ability, communication, motiv-
ation or preferences, environment, as well as life story
and medical examination. These are completed not in
order to quantify impairment but in order to identify
the mismatch between that impairment and the environ-
ment of the person concerned. This typically involves the
creation of a clear narrative or description of how an
intellectual impairment affects the person, and how
that impairment interacts with identified barriers in the
environment to result in challenging behaviour, which
itself sets up even more barriers for the person. For
example, consider an individual who has limited verbal
comprehension abilities and as a result they will be
impaired in their ability to understand much of the spo-
ken world around them. However, their environment
may not provide information in a visual sequence or in
a modified verbal format that takes account of their com-
prehension difficulties. This environmental failure to
adapt to the needs of the person may result in challen-
ging behaviour that has a purposeful outcome for the
person engaging in such behaviour. The person who is
unable to understand verbal instruction may aggress
towards others to remove such demands, or they may
aggress towards themselves to gain assistance in follow-
ing the instruction. Full behavioural assessment must
therefore identify the functional ability of the person
and the environmental context of the person. In this
sense, assessment goes beyond identifying the impair-
ment to identifying the dynamic interplay between
impairment and environment to result in an identifi-
cation of the adaptations that must be made within
that environment. There is also little interest from a
PBS perspective, which we believe is essentially a functional
perspective, in classification systems specifying the extent
of a given intellectual disability – such an approach has
been previously labelled as belonging to the medical
model of disability (Llewellyn & Hogan, 2000).
JOURNAL OF INTELLECTUAL AND DEVELOPMENTAL DISABILITY 7
This emphasis on the person and their environmental
context is clearly aligned with the social model insofar as
the interaction between the two is fully recognised. How-
ever, the social model as traditionally defined does not
elaborate on the types of context that influence the per-
son with disability and challenging behaviour, and, with-
out a delineation of these types of context, bringing
about social change or accommodation is made more
difficult. In this sense, the social model lacks a fuller
and perhaps more subtle appreciation of the varying
types of contexts and their relationship with intellectual
disability. Within the arena of challenging behaviour,
researchers and clinicians traditionally emphasised strat-
egies that concentrated on problem behaviour itself
rather than on the underlying deficiencies, such as
poor environmental conditions or a lack of functional
alternative skills (Carr et al., 1999).
Beginning in the 1980s, what came increasingly to the
foreground was the notion of a behavioural ecology or
the importance of the interplay of behaviours and the
person’s environment as “determiners of successful liv-
ing as well as the development of problem behaviour”
(Gaylord-Ross, Weeks, & Lipner, 1980, p. 39; Rogers-
Warren, Warren, & Baer, 1977). This was a shift that
would lead to profound consequences not just for the
concept of disability but also with respect to ideas of pro-
fessional practice. Specifically, the construct of disability
underwent a realignment from a focus on pathology or a
defect within the person to a conception of the interplay
between socioecological and person–environment fac-
tors. The result was a view of human functioning and
disability based on the interactions between personal
and environmental characteristics. A conception of dis-
ability in the context of person–environment inter-
actions and the role the environment can play in
supporting the person results not only in an enhance-
ment of an understanding of disability but also changes
the approach to assessment and intervention. Specifi-
cally, the focus of assessment orientates towards the
dynamic interplay between person and environment,
and subsequent intervention becomes orientated toward
the provision of the individualised supports needed
(Buntinx & Schalock, 2010). This particular emphasis
is also reflected in the idea of contextual fit within PBS
whereby the contextual factors affecting likely uptake
of interventions and environmental adaptations is an
increasingly common consideration. The emphasis on
social validity of interventions also reflects this concern
with the social context surrounding the person.
An examination of the design of PBS plans also
reveals a clear focus on a more ecological perspective
in relation to disability. One of the primary gains for
people with physical impairments via the social model
 8 I. GREY ET AL.
was the adaption of the physical environment to elimin-
ate or overcome barriers and to enable greater access to
aspects of their environments. PBS adopts the same
approach as a conceptual standpoint emphasising that
if the environment for people with challenging behaviour
is also adapted then the barrier of challenging behaviour
can be overcome. Support plans typically involve
environmental accommodations, direct interventions,
skills teaching, and reactive strategies. The first of
these, environmental accommodations, is central to the
principle of challenging behaviour as disablement insofar
as “the person can overcome behavioural disability to the
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extent that the environment can adapt to meet the needs
and characteristics of the person” (McClean & Grey,
2007, p. 656). Identifying the necessary environmental
accommodations can only come about through a com-
prehensive understanding of the person, and once the
features of the environment that may dispose the person
to challenging behaviour are identified, they can be
reduced or removed. However, a critical issue to under-
stand from a PBS perspective is that the term “environ-
ment” is not limited to the mere physical environment
but is broadened to include the interpersonal environ-
ment, the internal environment of the person, daily
structure, the extent of meaningful activity, and value
of that activity to the individual. This perspective relies
on the distinction between the need for the assessment
of both antecedent and setting events as conceptualised
in the literature pertaining to ABA (McGill, Teer, Rye,
& Hughes, 2003). Analysis of temporally immediate
antecedent- and consequence-based stimuli surrounding
problem behaviour is typically assessed by employing
antecedent-behaviour-consequence (ABC) observation
charts, for example. On the other hand, setting events
relate to complex states that impact on how someone
may react to a temporally immediate antecedent event.
To illustrate this we refer the reader to research by
McGill et al. (2003). The authors demonstrated that
social context, personal context, presence or absence of
others, activity, and even time of day are all events that
can increase the likelihood of the occurrence of challen-
ging behaviour. Analysing both antecedent and setting
events is core to identifying the appropriate environ-
mental accomodations or supports necessary. However,
although such supports can be interpreted as reflective
of a prosthesis conceptualisation in a similar way to
adaptive or assistive technology, some have argued that
such an approach is still reflective of a medical model
as there is insufficient emphasis on broader social change
(Oliver, 2007).
PBS has much in common with a supports model and
shares the same conceptualisation of support. It reflects
the critical role of the environment for the individual
and is tied to the same goals of providing normative
experience. In a sense, it can be readily argued that
PBS is a specific method for applying particular supports
for those with behavioural disability (i.e., challenging
behaviours). It can be argued that it produces change
on a more titrated and targeted social level to the specific
environment of the person displaying challenging behav-
iour. With respect to the issue of professional involve-
ment, PBS places a heavy emphasis on the provision of
staff to intervene directly with individuals with challen-
ging behaviour. These professionals should possess the
skills to both understand and alter rates of challenging
behaviour. A number of evaluations to date have also
demonstrated that staff can be trained successfully in
PBS (Grey & McClean, 2007; Lowe et al., 2007; McGill,
Bradshaw, & Hughes, 2007). This in itself represents a
shift away from a sole reliance on professionals to
bring about direct change in the lives of people with
intellectual disability and challenging behaviour. How-
ever, it should not be viewed as a means of negating
the need for professional therapeutic intervention, as
such individuals are required to disseminate effective
practices and the technology associated with those prac-
tices. Recent research demonstrates that training in the
practices of PBS has had a positive impact on the knowl-
edge, emotional responding, and attributions of staff in
relation to challenging behaviour. In addition, there is
growing evidence of reductions in levels of challenging
behaviour for individuals with intellectual disability
and challenging behaviour when frontline staff are effec-
tively trained in PBS by professionals with that expertise
(MacDonald & McGill, 2013). Furthermore, providing
support consistent with a PBS perspective encourages
individuals themselves, their families, and friends to
take leading roles in making decisions about the focus
of the services provided (Anderson & Freeman, 2000).
Under this supports model, people with specialised train-
ing and experience are available to help develop strat-
egies to achieve desired goals. To this end, effective
application of the practices of PBS almost always
involves a team-based approach.
Environments can be modified, reconstructed, and
even created, so capacity emerges to the extent that a per-
son is enabled to engage in the environment in which the
individual develops (Fawcett et al., 1994). In addition,
there is a heavy emphasis within a PBS framework on
the immediate social context of challenging behaviour
and by default the manner in which social interaction
can bring about and prevent challenging behaviour.
This is reflected in the PBS core premise that challenging
behaviour primarily serves a communicative function for
the person displaying such behaviour. It is how the
environment (including others in the environment)

responds to such behaviour that serves to either remedi-
ate or increase challenging behaviour. PBS harnesses the
technology associated with an operant conditioning
paradigm to produce a pragmatic understanding of per-
son–environment interaction through an operant frame-
work that can result in real change for the person with
challenging behaviour. As such, we believe that PBS is
clearly up to the task of meeting the definition of a sup-
ports model. The greatest contribution of the social
model has been to generate an overt focus on the inter-
action between the person and environment in creating
the experience of disability. This theme is fully reflected
Downloaded by [National University of Ireland - Galway], [Helena Lydon] at 01:48 01 April 2016
in PBS, and the interplay between person and environ-
ment has been at the heart of operant psychology for
over 70 years.
The second component of support plans, skills teach-
ing, is at the core of PBS. Although some authors consider
educational interventions (which skills teaching could be
categorised as) to reflect a medical model agenda (Juno,
2007), the emphasis that underpins skills teaching in
PBS is to enhance the person’s ability to exert control
over their own environment and indeed over their own
life. The end goal is to help develop a sense of mastery;
to meaningfully choose, to meaningfully engage, and to
have a better quality of life. Skills teaching includes target-
ing functionally equivalent skills, general skills, and also
coping and tolerance skills. The first component is con-
cerned with identifying and providing the person who
displays challenging behaviour with alternative socially
acceptable means of gaining the same result as brought
about by challenging behaviour. Effective skills teaching
relies heavily on the conceptual framework provided by
operant psychology. Early applications of operant psy-
chology to the field of disability may be readily classed
as behaviour management/modification and attempting
to change the individual, but such a perspective is out-
dated (ProfHastings, 2013).
A third component of behaviour support plans typi-
cally involves altering contingency arrangements. The
aim of intervention from this approach is to ensure
that the environment is arranged in such a way that
appropriate behaviours are followed by maintaining con-
sequences where target behaviours for reduction are not.
The goal here is to build or strengthen (through
reinforcement contingencies) appropriate skill reper-
toires for the person. The arrangement of such contin-
gencies in the manner described previously is also
referred to as promoting desired behaviour (Dunlap
et al., 2009). This is not to be misconstrued as social
engineering to achieve what is considered socially accep-
table and somewhat artificially selected but to the end of
having a behavioural skill set that aids the person to live a
life of their choosing.
JOURNAL OF INTELLECTUAL AND DEVELOPMENTAL DISABILITY 9
There is at least one risk, however, for the future of
PBS and that is it may become an exclusively value-dri-
ven entity and one decoupled from efficacy in being able
to bring about meaningful change for individuals who
display challenging behaviour. It must be remembered
that PBS emerged as an approach from the behaviour
analytic literature to understand and intervene upon
challenging behaviour because of (a) a strong commit-
ment to both values and nonaversive behavioural tech-
nology, and (b) because the
basic foundation of PBS presupposes that the valued
elements of personal life … depend at some level on
our ability to behave competently. Defining the technol-
ogy that allows people to more closely achieve the life-
style they value is at the heart of PBS. (Dunlap et al.,
2009, pp. 3–4)
and this technology is drawn from ABA. As a result of
the need for effective technology in behaviour change,
it is clear that PBS practitioners need a very thorough
grounding in both the technology and philosophy of
the science of ABA. For many practitioners and service
agencies, PBS represents a merging of empiricism and
value, but it has been put forward that PBS may jettison
behavioural theory as it claims to adopt a broader con-
textualism and pragmatism (Singer & Wang, 2009).
We argue that this would be a grave mistake. At its
core, PBS should and must be concerned with the deliv-
ery of effective behavioural supports, which have been
proven to help remove the barriers caused by challenging
behaviour to access activity, community, and a meaning-
ful quality of life. To downplay the importance of these
supports would adversely affect PBS and inevitably result
in poorer outcomes for individuals with challenging
behaviours. The history of disability is peppered with
examples of often well-intentioned ideas without the
means to make them a reality. That is not a welcoming
road either for PBS or for individuals with challenging
behaviour. A related risk is services adopting the lexicon
of PBS but not its core practices, or not recognising the
fundamental skills and training for practitioners, as
well as the underlying scientific principles on which
these are built.
Conclusion
Models of disability refer to frameworks for understand-
ing the causes of disability and, by implication, the
means to ameliorate them (Altman, 2001). Models also
exert considerable influence in respect of the adoption
and validation of professional practices (Buntinx & Scha-
lock, 2010). Although the medical and social models of
disability are most discussed in the literature, both are lim-
ited with respect to being able to bring about effective
 10 I. GREY ET AL.
meaningful change for individuals with challenging
behaviour. The medical model does not provide a tem-
plate with which to understand how specific idiosyncratic
contexts affect impairment, and the social model, while
recognising the distinction, often fails to identify the fre-
quent idiosyncratic supports that an individual might
need, at the expense of calling for collective social action
to reduce the effects of a disabling society. However,
both models have been portrayed rather simplistically in
the literature and it can be argued that both have
“moved on” since the initial debate about their relative
merits and disadvantages began in the early 1980s (Oliver,
Downloaded by [National University of Ireland - Galway], [Helena Lydon] at 01:48 01 April 2016
1983). Nonetheless, the question of their respective utility
for generating effective approaches to challenging behav-
iour remains a valid one. A supports model of disability
offers more insight into the nature of disability and the
occurrence of challenging behaviour but to date has
only been infrequently discussed in this context. However,
ABA has been previously identified as sharing character-
istics associated with a transactional approach and sup-
ports conceptualisation (Bricout et al., 2004). Therefore,
a PBS perspective can be considered more reflective of a
supports model of disability, grounded in the context of
the individual person and focusing on the need for change
on various levels, including the immediate environment,
their social interactions, and the specific systems sur-
rounding the person. PBS brings with it a set of values
that emphasise quality of life, self-determination, and
choice tied to a nonaversive technology that can achieve
those outcomes. At its core, therefore, PBS is about build-
ing an ecology of support for individuals with intellectual
disability and challenging behaviour. One of the great
strengths of the behavioural tradition within PBS is its
insistence on working out very carefully a description of
what a change agent needs to do in order to build this
ecology at the level of the individual.
Discussions of models of disability have been an
important topic in the field of disability to date. Models
are useful in the sense that they may operate as concep-
tual frameworks from which to guide an understanding
of disability and related service delivery and develop-
ment. However, both the medical and social models
may be best understood at this point in time as represen-
tative of the early stages of disability research (Llewellyn
& Hogan, 2000) and as useful benchmarks by which to
determine current progress. PBS, while sharing many
of the values of a social model, goes beyond this to pro-
vide the means to identify and deliver the specific sup-
ports by which quality of life at the level of the
individual with intellectual disability and challenging
behaviour can be achieved. It can simultaneously offer
the means to capture both a micro and macro analysis
of the environment in which the individual functions
and utilise an effective technology to bring about real
change for the individual displaying challenging behav-
iour. This promise explains in part why disability ser-
vices in several countries have adopted PBS. However,
PBS must also deliver on this promise, and although a
substantial body of research regarding efficacy has devel-
oped over the past 25 years, more is needed in specific
areas. These include (a) how cost effective are supports
delivered through PBS; (2) how to ensure that the quality
and integrity of behaviour support plans are maintained
within services; and (3) do the supports offered within a
PBS framework improve quality of life for the individual
with intellectual disability across social, interpersonal,
and occupational domains. Models of disability are use-
ful not only to understand disability but also to inform
practices, and those practices must be tied to desired out-
comes. At its simplest level, models must specify desired
outcomes and practitioners working from those models
must determine their effectiveness in bringing about
desired outcomes.
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