Brief Description of PBS Related to Mental Health and Child Welfare
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Positive behavior support planning includes an emphasis on both biomedical and behavioral science. An effective PBS plan is based upon gathering information about the internal physiological issues that may either trigger problem behavior or increase the likelihood that an individual will engage in problem behavior. The process for identifying the role of both internal physiological states and how environmental events are related to the occurrence of problem behavior is called functional behavioral assessment or FBA. The FBA process provides a systematic process for gathering information that helps us understand what is maintaining a child or adult's problem behavior. Individuals engage in a behavior because it is functional; it helps a person acquire some form of reinforcement (e.g., they get something desirable or pleasant, or they avoid something undesirable or unpleasant). A person may engage in problem behavior because circumstances in the external environment (i.e., antecedents) trigger or ‘set the stage' for this behavior to occur. However, these "triggers" can be events that occur within a person as well; examples of physiological triggers include anxiety, pain, psychotic episodes, or illness. FBA research indicates that a significant number of individuals engage in problem behaviors that are not linked to social or environmental functions. In these cases, biomedical factors play a part in explaining the occurrence of problem behavior.
Even when a person's behavior is clearly maintained by a social function, physiological events can increase the likelihood of problem behavior. When a physiological event increases the likelihood that a person will engage in problem behavior, it is referred to as a setting event. Setting events set the stage for problem behavior and temporarily change the way in which a person responds to people, situations, or settings. For instance, an adult with a disability may also have a mental illness that results in periodic psychotic episodes. During these episodes, this individual may be more likely to engage in certain types of problem behaviors in order to escape from confusing situations, task demands, or activities the person normally enjoys. When the individual experiences a psychotic episode, he may find it more reinforcing to seek out a quiet place to be alone.
In other cases, a mental illness may directly trigger problem behavior. Physiological arousal related to an anxiety disorder, for example, may be a trigger (a trigger is also referred to as an antecedent event) for problem behavior since it immediately precedes the occurrence of problem behavior. For example, a highly anxious person might be more likely to engage in aggression or self-injury when his or her heart is beating fast and he/she is out of breath. The FBA identifies the times or situations that are associated with higher levels of physiological arousal so that this information can be used later to design intervention approaches. Activities may be modified so that games involving other peers are not scheduled during high arousal periods in order to prevent problem behavior. Another example might be to teach a person to identify signs of increasing arousal and learn to engage in activities that help him/her relax. The FBA process can provide important data related to cyclical patterns of problem behavior. For instance, cyclical behavioral patterns can become apparent during observations across a twenty-four hour period. These cyclical patterns may help team members understand the best times to encourage social outings, schedule learning opportunities, and increase independence.
Medications often change how individuals respond to their environment. Side effects from medications that are taken for many different physical and mental health issues can have a big influence on the occurrence of problem behavior. Individuals who have been diagnosed with seizures disorders, anxiety-related problems, schizophrenia, depression, and many other types of diagnoses may experience problems when transitioning to a different dosage or medication. All of these types of experiences can also set the stage or trigger the occurrence of problem behavior.
Another issue that should be taken into consideration during a FBA process is that over a period of time, problem behavior that is initially maintained by physiological or mental health influences can become reinforced by subsequent social outcomes. For example, an adult with a disability who engages in self-injurious behavior which was triggered due to a short-term illness (psychiatric or otherwise), may receive higher levels of attention from family members and others. Even after the short-term illness ends, this adult may continue to engage in self-injury since he has learned over time that self-injury results in a higher level of attention from others.
Partnerships with Mental Health Professionals
Specialists in medical and behavioral professions do not always address problem behavior in an integrated and collaborative fashion. Mental health professionals receive training that emphasizes treatment using medical interventions, while practitioners in education and psychological fields are more familiar with interventions that emphasize instructional strategies that are based on teaching skills and changing aspects of the settings in which a person lives. Psychologists and behavior specialists are often called in to support a person engaging in problem behavior, while psychiatrists and medical professionals are consulted for issues related to illness or disease. An integrated service planning process is necessary to ensure individuals with complex mental health and behavioral needs receive the support necessary to experience a high quality of life. Behavioral support approaches may only be partially successful if health-related issues are not addressed. In fact, PBS plans should begin with a full medical check up before an FBA process is started. If pain or illness is triggering problem behavior, treatment for these issues may make PBS planning unnecessary.
More opportunities are needed for mental health, educators and human service professionals to work together, share common strategies, and coordinate services . Recently, the Bazelon Center for Mental Health Law created a roadmap for policy-makers that clearly describes the importance of connecting health systems with school-wide positive behavior support (SWPBS). This roadmap is called "Way to Go: School Success for Children with Mental Health Care Needs". Information included in this document describes how states and school districts have successfully combined school-wide positive behavior support (PBS) with effective mental health services to foster a school environment that is conducive to learning and improves children's lives.