The importance of “Allies” in Positive Behaviour support.

A multi-disciplinary approach

Positive Behaviour Support is an evidence-based approach which is primarily aimed at improving a person’s quality of life. It is intended to reduce behaviours identified by the person and/ or their support network that have caused or have the potential to cause harm, consequently reducing the need for any practices that may be restrictive or infringing on their human rights.

Typically, it involves the development of a Positive Behaviour Support Plan via a comprehensive assessment of a person’s behaviour, lifestyle, environment, and a support system. We use empirical methods to determine WTF… What is The Function of the behaviour? When the function of a behaviour is determined, a functionally equivalent behaviour is implemented, to assist the person to get their needs met in a way that is safe and more effective. For instance, teaching a new communication response (ie. ask for a break) when overwhelmed.

As allied health/behaviour practitioners, we are ethically required to work within a scope of practice, and to be aware when we need to consult with other professionals to determine the root cause of a behaviour of concern.

Physical

First and foremost, its important to determine what is going on physically for the person. A great place to start is a CHAPs review (Comprehensive Health Assessment Program) with a General Practitioner. A doctor or nurse can determine the intersection between health and behaviour such as pain levels due to pressure sores, mood swings due to diabetes, excessive urination due to an enlarged prostate etc.

An assessment with Physiotherapist can determine if assistive technology, or equipment is appropriate or if it is causing pain, discomfort or frustration. I once observed a shower chair that was too small taking away a persons ability to engage in their own personal care and independence, when they previously could. Wouldn’t any of us be frustrated under those circumstances? I regularly observe a reduction in behavioural incidents, when the right equipment is provided.

A swallowing assessment with a speech pathologist may be required if a person is choosing not to eat, drink or take medication, to determine if there is a physical cause. A functional capacity assessment by an Occupational Therapist can determine gaps in supports. In addition, the capacity of the person needs to be assessed before implementing any interventions. I have seen plans that look great on paper, (ie. pressing a button when wanting attention) without the consideration if the person has the physical capacity to do so.

Psychological/ Cognitive

Most health practitioners can do screeners for mental health, such as a Depression, Stress, Anxiety Scale (DASS), however, when there are significant mental health concerns, a psychologist or psychiatrist is required to diagnose and treat. If there is a traumatic history, familial attachment issues, addictions, concerning symptoms of self-harm and aggression etc. it is important to have a psychiatric review. For instance, a mental health practitioner can assess if the symptoms are most likely related to an intellectual disability (ie. confabulation or self-talking) or a psychosis (ie. hallucinations or delusions). Historically anti-psychotics or neuroleptics have been commonly prescribed for behavioural management, however, this is now deemed a chemical restraint and legislated. Ongoing annual medication reviews with a psychiatrist are imperative and an assessment with a geriatrician may be required if there are significant changes noticed ie. confusion, memory loss, disorientation, to determine if there is Alzheimer disease. Research estimates that 50% of people with down syndrome will develop dementia.

In addition, I regularly see reports that incorrectly assume a person’s cognitive capacity. I was once informed a person had no cognitive issues, when in fact they could not remember their own name and had a moderate intellectual disability. These assumptions can make supports have much higher expectations of the person’s capacity, and a cognitive assessment can give a better understanding of “can’t vs. won’t.”

Communication

All behaviour is communication! A communication assessment with a Speech Pathologist is highly beneficial to determine a persons receptive vs. expressive abilities. It is common for supporters to overestimate what a person can understand when their expressive communication is good. Conversely, just because a person cannot express themselves verbally, it does not mean they don't understand when others are speaking to and about them! This can also determine the best strategy to assist the person to communicate, such as a communication device/dictionary or signs.

Sensory

A sensory profile with an Occupational Therapist can provide an overall picture of a persons sensory processing patterns. This can determine the “setting events” or the conditions/environment that make behaviours of concern more likely. Some sensations may be highly uncomfortable or even painful to the person, for instance hyperacusis (pain in the ear due reduced tolerance for sound) to certain sound frequencies. This is particularly important if there are self-injurious behaviours, as the person may be lacking sensory inputs or experiencing sensory overload. A sensory assessment can help to inform helpful interventions, such as massage therapy, music, sensory objects, smells that may be comforting and assist to calm the nervous system.

There are a plethora of additional “allies” that can provide information on a persons needs, what they are trying to communicate through behaviour and assist to implement interventions, such as dieticians, nurse navigators/educators, exercise physiologists, music therapists, yoga instructors, massage therapists, personal trainers etc.

There are overlaps between our allied health specialisations, and we can generally screen for deficiencies. When it is beyond our scope of practice, we require additional support and consultation from other health practitioners. Working as a part of a multi-disciplinary team is imperative to deliver effective Positive Behaviour Support and create the best outcomes for those the people we serve.