CYPS PBS Pathway and development

of the CYPS Intensive Positive

Behaviour Support Team

Dr Nicola Dodds – Principal Clinical Psychologist

Dionne Hollis – IPBS Pathway Manager

Dr Gill Legg – Consultant Clinical Psychologist

The need for Positive Behavioural

Support (PBS)

• Children with learning disabilities can be at risk of developing behavioural difficulties that can be a challenge.

• Risk factors include impaired communication, impact of cognitive deficits, and potentially additional sensory, physical and mobility needs (Emerson 2011)

• Approximately 40,000 children with learning disabilities may present with behaviour that can challenge services and others (Challenging Behaviour Foundation 2014)

• Positive Behavioural Support is an evidence based approach which provides a multi-element framework to assessing, behaviour and working with stakeholders to write an intervention plan.

• Identifies the need to address carers and parents optimism as a key factor alongside interventions (Durand 2011)

PBS: as a multi-element framework

• Based on VALUES – prevention of challenging behaviour occurs in context of increased quality of life. Uses approaches to build skills and reduce restrictive responses to behaviour

• Based on THEORY and EVIDENCE BASE– an understanding that challenging behaviour serves important functions and gets needs met

• Uses applied behaviour analysis to assess and support behavioural change

• Has a clear PROCESS including data driven approach, functional assessment, and multi – component interventions to change behaviour pro-actively and respond to behaviours reactively

• Support , monitoring and evaluation of interventions over long termGore et al (2013)

Positive Behavioural Support is…

• Non-judgemental (working together as equals)• Everyone working together using a shared plan• Child is at the centre of this plan• Everyone feeling more confident, optimistic and skilled in

supporting the child• Child learning new coping strategies and new skills• Creating more opportunities to make life better e.g going out and

doing more things together• Based on what is important to a child and their family as well as

what is perceived to be important for the person.• Works with the families goals, and what is realistic within the

context of the family life and value base

Strategy for implementing PBS in CYPS

Workforce development functional assessment and

interventions

Pathways and structures that support

clinical process

A data driven approachQuality of data,

Behaviour Support Plans and Implementation

standards

The initial PBS pathway – identifying needs

Limited complexity

Parent focused

Initial plan

6 sessions

multiple functions /

Behaviour Support Plan

12+ sessions + specialist assessment

Brief ----Full FA

Functional Analysis

Initial assessment

Further assessment

Further assessment + intensive support*

Inpatient Intensive assessment

Community Inpatient

Successes and Challenges

• At time of development - not enough staff with a PBS qualification to complete further complex assessment in community

• 4 staff completed PBS Advanced Professional Diploma (8 ongoing)

• 5 staff completed PBS Professional certificate

• 2 BCBA’s

• Needed to develop a standard initial brief assessment

• Developed initial assessment pack which is used in all areas now and MSc project showed promising results

• In house training has continued to be offered in delivering initial assessments and training has been delivered to Cumbria teams also

• Needed intensive support team

• New IPBS team formed through NEW CARE MODELS

What are “New Care Models”?

• Part of NHS England’s ‘Five Year Forward View for Mental Health’

• National pilot

• Opportunity for secondary mental health providers to take

responsibility for tertiary commissioning budgets and

demonstrate ability to innovate and transform services in the best

interests of service users and their families

NTW is delivering “Transforming

Care” through New Care Models

New Care Models fundamentals are to:

• Reduce reliance on inpatient beds

• Reduce length of stay

• Provide Care closer to home

• Reduce out of area placements

Things to remember!

• No “new” money

– We can use funds released from bed/ward closures

– We can use funds we’d otherwise spend sending patients “out of

area”

• Not about doing “more of the same” in community

– CCGs fund community services

– NCM is to fund “enhancements” – typically new services aimed

at caring for people “locally” and avoiding admission where

possible

Intensive PBS service: Aims

• To prevent admission to hospital

• Prevent home breakdown

• Maintain community school placement

• Maintain respite and social care support

• To work with educational/social care provision if sign posted for

residential provision

• To assess the need for inpatient assessment ( Fraser House)

Intensive PBS service: population

The team covers a geographical area that includes:

• North Cumbria

• Northumberland

• North Tyneside

• Newcastle

• Gateshead, Sunderland and South Tyneside

working with Children and Young People’s services that are responsible

for providing specialist learning disability services to children and young

people up to the age of 18.

• TEWV developing enhancement to existing services

NCM : Developing the PBS pathway

to meet population needs

• South of Tyne NTW Project

Gaps and identified needs in existing PBS pathway

• Enhanced ICTS, implementation of Crisis Plans

• Use of Care Education and Treatment Reviews

• Further PBS assessment for complex cases

• Early interventions & Parenting support

• Dynamic Risk Register

• Crisis Plans and Support

Dr Nicola Dodds 2018

Intensive PBS team +

Community and ICTS within NTW

PBS pathway development

The story so far…

• Enhanced Intensive Care and Treatment Service (ICTS)– Training in

LD and ASD completed

• Intensive PBS team formed (IPBS)

• Bi-monthly PBS CYPS network meeting with community, ICTS,

Intensive PBS and inpatient represented in NTW

• PBS Consultations with community teams set up monthly

• PBS workforce development plan+ set up community of practice

• Link to new Trust PBS Steering group and regional PBS steering

group

IPBS core functions of support

Further assessment and PBS interventions

- Functional assessment and Behaviour support plans

- Positive Family Intervention as a core component for intervention

to help families write their own BSP and addresses optimism and

resilience

- Supporting the implementation of plans through modelling and

coaching

• Provision of support and person specific training for other agencies

supporting those children and young people

• Co-ordination of transitions from inpatient and other settings

• Support the development of robust crisis and contingency plans that

work across agencies including local CYPS teams, ICTS, education

and social care

Intensive Support Pathway

• Week 1- 3 – observations, assessments, interviews. Crisis contingency plans and focused support strategies. PFI commenced

• Week 4- 8 – developing the BSP with key implementers, summary statements of functions of behaviours, and meaning. At a glance BSP plan produced. PFI sessions continue

• Week 8 – 12 Implementing Plan and Plan development in PFI

• Pairing ourselves with preferred activities, establishing ourselves as reinforcers.

• Antecedent control, high density of preferred activities. Satiation

• Teaching replacement skills• Reward programmes• Primary + prevention strategies –

environmental, interactions, communication strategies

• Non-aversive reactive strategies

• Coaching and feedback as we implement strategies

IPBS team structure

PBS pathway workforce delivery plan

Foundation level PBS Skills – training for all

• Day 1: Understanding Behaviours Which Challenge

• Day 2: Understanding Behavioural Support Plan

Implementation level Skills – training for specific role/ function on the pathway

• Day 3: Service Specific –

Community team: Initial Assessment

ICTS: How to use PBS in a crisis

Inpatient and IPBS: Further/Intensive Assessment and how to use At a Glance plans effectively

PBS work force plan

Advanced / Supervisory level PBS Skills – training for PBS completing further/ intensive assessments and who can supervise others

Recognised qualification such as

• Advanced Professional Diploma (Wales)

• BCBA

• Need for MSc PBS course

• PBS supervision group and PBS consultations to support learning and application of skills

PBS skill gaps and identifying needs

across whole pathway

• More PBS practitioners / Supervisory level needed in each

team

• Need to develop a better “fit” of training to specific specialist

role, and develop PBS Practitioner roles.

• Need for equitable resources across teams to deliver data

driven approach e.g assistant psychologists, and access to

specialist assessments e.g SALT

• Need for appropriate certified training route for Assistant

Practitioners/ support workers so can develop within PBS key

implementer roles – Apprenticeships in future

• Current courses self directed and online can take time/ not be

completed – need to access local courses supported by

Supervisors in service

Conference: “Steering through the crisis” -

How PBS offers families hope through action

3rd – 5th April 2019

Day 1: Help and Hope: Combining PBS and Optimism Training for Parents of

Young Children with Challenging Behavior. Shelly Clarke, M.A., BCBA

Day 2: Working with families to help implement change. Using Coaching,

modelling and Feedback skills, and an Active Support Model. Professor

Sandy Toogood, Senior Lecturer in Applied Behaviour Analysis, Bangor

University

Day 3: Using a PBS model for high severity behaviors: considerations to

support implementers and receivers of care. Dr. Elizabeth Hughes, PhD,

Clinical Director of the Institute for Applied Behaviour Analysis

Have now led to Regular Practice Development days for CYPS in the Region

– follow up day July 2019 and next planned for November 2019

Learning so far….

IPBS consultations – monthly with each community team

• Cases discussed presenting with behaviours of high severity

• Risk factors are present that make crisis likely e.g respite break down, school exclusion

Themes

• PBS initial assessments completed

• Difficulties in implementing PBS plans – resources and support for families

• Family stress levels and burn out

Intensive PBS Team – Activity

IPBS consultations – till end of March 2019

Area consultations Cases discussed more than once

Led to referral

Newcastle/Gateshead 8 2 2

Cumbria 2 0 0

Northumberland 8 1 1

Sunderland 8 1 2

TOTAL 26 4 5

IPBS Evaluation Planned

Further Assessment, treatment and support for individuals who

display behaviour that challenges

• Specialist Assessment will be provided by a specialist MDT leading

to a Positive Behaviour Support Plan

• Families will be involved in this process with plans being produced

together with professionals which are the best fit for them

• Outcome Measurement: Carer concerns reduction

• Health outcomes improved (Honosca). Behaviours of concern

reduction (behavioural data). Hospital admissions reduced.

IPBS Evaluation Planned

Provision of support, and person specific training for other agencies supporting those children and young people

• Positive Family Interventions delivered to families to support the understanding, resilience and skills in responding to complex behavioural presentations in their child. Outcome measures include Brief Parent Self Efficacy Scale and Questionnaire on Resources and Stress.

• An increase in skills in the regional workforce in services which support children and young people such as respite provisions, schools. Outcome measures: include pre and post confidence ratings following training. Implementation rates for PBS plans.

• Evaluation of impact of consultations

IPBS Evaluation Planned

• Coordination of transitions from inpatient and other

settings

• Assisting in the transitions from inpatient and other settings.

• Developing the capability in families / carers who will be providing

support and provide individual bespoke training. Expertise in PBS

available at times of transition and assistance in implementing and

monitoring a PBS plan.

• Outcome measures: length of stay reduction, Parent/ carer

confidence and satisfaction

IPBS Evaluation Planned

• Support the development of robust crisis and contingency

plans that work across agencies including local CYPS teams,

ICTS, education and social care

• Specialist risk assessments relating to behaviours of concern, and

contribution to crisis and contingency plans which are multi-agency

in approach.

• Outcome measures are reduction in risk behaviours (behavioural

Data). Reduction in admissions to hospital and out of area

placements. Time spent in hospital if admission occurs reduced.

• Any questions?