Journal of Applied Research in Intellectual Disabilities 2007, 20, 615

Service User Outcomes of Staff Training in

Positive Behaviour Support Using
Person-Focused Training: A Control Group
Study
Ian M. Grey* and Brian McClean
*KARE Services, Newbridge, Co., Kildare, Ireland, School of Psychology, Trinity College, Dublin, Ireland, Brothers of Charity,
Roscommon, Ireland

Accepted for publication

19 June 2006

Background Effectively supporting individuals with intellectual disabilities who display challenging behaviours
continues to be a priority for service providers. Personfocused training (PFT) is a model of service delivery
which provides staff with skills in functional assessment
and intervention development. Existing longitudinal
data from a study of 138 cases suggest that implementation of staff-developed behaviour support plans through
PFT is effective in reducing challenging behaviour in
approximately 77% of cases [McClean et al. Journal of
Intellectual Disability Research (2005) vol. 49, pp. 340353].
However, no control group was used in this study.
Method The current study involves the use of a control
group of individuals with challenging behaviours
matched against those selected for PFT over a 6-month
period. Groups were matched on type of challenging
behaviour, duration of challenging behaviour, gender
and level of disability. Information on the frequency,
management difficulty and severity of challenging beha-

Introduction
The detrimental effects of challenging behaviour among
people with intellectual disabilities are well known.
Behaviours such as physical aggression, self-injury or
property destruction can threaten an individuals residential placement (Bruininks et al. 1988), interfere with
opportunities for social interaction (Anderson et al. 1992)
and community participation (Larson 1991). Indeed
challenging behaviours are most commonly defined in
terms of their capacity to impede access to or enjoyment
of community facilities (Emerson & Emerson 1987).
Unfortunately, there are relatively few studies which
2007 BILD Publications

viour was collected pre- and post-training using the

Checklist of Challenging Behaviours (CCB) for both
groups. Observational data were collected for the target
group alone. Rates of psychotropic medication were
tracked across the training period.
Results Significant reductions in the frequency, management difficulty and severity of challenging behaviour
were found for service users in the target group but not
in the control group after 6 months. No significant changes were found in the use of psychotropic medication
for either group over the 6-month period.
Conclusion Overall results suggest that PFT is an effective model for providing support to individuals with
challenging behaviours.
Keywords: challenging behaviour, positive behaviour
support, applied behaviour analysis, control group, service delivery, psychotropic medication

provide accurate information on the prevalence rates of

challenging behaviours. In the UK, prevalence rates of
approximately 8% have been reported (Emerson &
Bromley 1995) while in the Republic of Ireland, rates as
high as 28% have been recorded (McClean & Walsh
1995a,b) although such discrepancy is most probably
attributable to varying definitions of challenging behaviour. Consequently, services are frequently presented
with the question of how to effectively support individuals who display such behaviour. Despite a large body
of empirical work in the area, data suggest that services
continue to struggle with this question. In a study of
265 individuals with challenging behaviour, Robertson
10.1111/j.1468-3148.2006.00335.x

Journal of Applied Research in Intellectual Disabilities 7

et al. (2005) identified that only 15% had a written behaviourally orientated treatment programme and, of these,
many were simplistic. Furthermore, in a Canadian sample of 625 adults and children with intellectual disabilities and challenging behaviours, Feldman et al. (2004)
found that 97% of individuals were receiving some form
of intervention but that the majority of these were informal (55%) (i.e. simplistic, poorly recorded and typically
not evaluated). Such data would suggest that many
individuals with intellectual disabilities are not in
receipt of therapeutic interventions for challenging
behaviours drawn from an established evidence-base.
Pharmacological and behavioural interventions represent the dominant intervention approaches currently
available in the area of challenging behaviour (Grey &
Hastings 2005). Research to date has consistently
reported that many individuals with challenging behaviour are in receipt of psychotropic medication. One
rationale for such treatment is based upon the premise
that challenging behaviours may represent an atypical
manifestation of a psychiatric disorder. However, there
is a wide variation in the frequency of psychotropic
medication usage to reduce the occurrence of challenging behaviours with rates as high as 61% reported in
some groups (Harper & Wadsworth 1993). Additionally,
the high prevalence rate of psychotropic medication is a
cause for concern given the lack of empirical data on
their effectiveness (McGillivray & McCabe 2004; Singh
et al. 2005).
Interventions drawn from applied behaviour analysis
can be effective in supporting individuals with intellectual disabilities who display challenging behaviours
(British Psychological Society, 2005). Reviews suggest
that behavioural interventions based upon the results of
functional assessments are effective in reducing the
occurrence of challenging behaviour (Carr et al. 1999;
Grey & Hastings 2005; McClean et al. 2005). Hence it is
no longer the task of practitioners in the field to demonstrate the efficacy of applied behaviour analysis, rather
the task now is one of effective dissemination (Emerson
2001).
However, this is not a task that has attracted as
much focus as it warrants. One reason for this may be
that many services have opted for the specialist team
model to deliver behavioural supports. In this model, a
small number of specialists with expert knowledge of
applied behaviour analysis conduct and deliver interventions (McClean & Halliday 1999). The primary difficulty confronting such teams is one of logistics
(Emerson & Forrest 1996). The number of specialists
required to meet the needs of people with challenging

behaviours may not be available (Sprague et al., 1996).

In a survey of 46 peripatetic teams, Emerson & Forrest
(1996) found that 49% of teams carried caseloads of
between one and six cases and that caseloads range
from 1 to 25. The authors report that only 48% of people with severe challenging behaviours were on current
team caseloads. There are simply not enough psychologists or other specialists to provide the service that
people with challenging behaviour need. Without adequate throughput, the specialist team may fail to provide the specialist support services required.
One of the most discussed developments in supporting individuals with challenging behaviour in recent
times has been that of positive behaviour support (PBS).
PBS is an approach to support derived from social, behavioural and biomedical science that is applied to achieve
reduction in challenging behaviours and improved quality of life (Knoster et al. 2003). The core elements of PBS
involve: (1) the use of comprehensive functional assessment involving all stakeholders and intervention agents
to achieve a contextual fit in typical service settings. This
typically entails that functional assessments are conducted in routine service settings, (2) altering deficient environmental conditions, (3) altering deficient behaviour
repertoires and (4) achieving lifestyle change through
multi-component behaviour support plans while
decreasing the frequency of challenging behaviour (Snell
et al. 2005). These elements revolve around the hub of
the PBS team which comprises all relevant stakeholders
using a collaborative rather than expert-driven approach.
One additional feature of PBS that is discussed less
frequently than those above is its approach to training.
Implicit within the model is that training does not follow
the trajectory where strategic information is simply
transferred from experts to service providers but is
rather as a process of mutual education carried out in
on-site settings rather than in the confines of universitybased locations (Carr et al. 2002).
To date, one large review of PBS has been conducted
(Carr et al. 1999). This review of outcomes associated
with PBS suggests that PBS is effective in reducing the
challenging behaviour in one-half to two-thirds of
cases. It also suggests that success rates almost double
when interventions are based upon a prior functional
assessment. Recent studies have examined the extent to
which PBS characteristics or processes such as functional assessment and stakeholder participation actually
occur in practice. Snell et al. (2005), using a sample of
111 studies over a 5-year period involving school-age
children with disabilities, identified that the involvement of intervention agents and the use of routine

2007 BILD Publications, Journal of Applied Research in Intellectual Disabilities, 20, 615

8 Journal of Applied Research in Intellectual Disabilities

settings were not a frequent characteristic of assessment processes employed. Multiple- versus single-component interventions were commonly reported but
typically involved a maximum of two or three interventions. Only two-thirds of studies reported the use
of antecedent procedures and only half reported teaching functionally equivalent skills as an intervention.
The conclusion reached by the authors is that the PBS
standards of using a comprehensive approach with a
focus on prevention through altering environmental
conditions and teaching functionally equivalent skills
are not extensive in current assessment-based research.
However, these findings may not be representative of
typical service settings as the majority of assessments
were conducted by researchers and belie an emphasis
on a minimal number of interventions to allow
research standard evaluation. Furthermore, this study
did not include any consideration of the role of training for primary care staff which Carr et al. (2002) identify as central to PBS. Attempts to define PBS typically
include its reliance on functional assessment, goal of
quality of life improvement and the use of multi-element interventions. An element of PBS is the involvement of staff in a manner that elevates them to a
central role rather than that of an information provider,
but how to successfully achieve this is rarely identified
in the literature. This may explain its absence as a
selection criterion in this most recent evaluation of PBS
practices.
One large services-based study of PBS is available
which clearly identifies a method of placing staff at the
very centre of the delivery of PBS. McClean et al. (2005)
have developed a method of delivering PBS through a
model called person-focused training (PFT). The model
involves training staff who work with service users displaying challenging behaviour to conduct a functional
assessment, to design and to implement a multi-element
behaviour support plan for this person. Assessment
includes a comprehensive psychosocial assessment,
incident analysis, functional assessment and hypothesis
testing. Intervention involves environmental accommodation, skills teaching, direct interventions and reactive
strategies. Implementation involves periodic service
review (LaVigna et al. 1994) and quarterly progress
reports. Such an approach meets the key standards of
PBS (e.g. multi-element interventions are developed
from functional assessments by the primary care staff
who are the also the primary intervention agents).
An analysis of longitudinal data from 138 staff-developed behaviour support plans indicated that significant
improvements were observed in 77% of cases (defined

as a reduction to below 30% of baseline rates of behaviour) and that at an average follow-up of 22 months
such improvements were maintained. Unfortunately,
there was no control group and hence it remains unclear
whether reductions in challenging behaviour would
have occurred over the same time period. However,
recent studies have identified that challenging behaviours remain chronic in the absence of appropriate
intervention and therefore it is unlikely that such
improvements would have occurred naturally (Stancliffe
et al. 1999; Watson et al. 2001; Thompson & Reid 2002).
The current study has as its primary goal to determine
whether training staff in the assessment of challenging
behaviour and the development of behaviour support
plans will result in reductions in challenging behaviour
for clients with whom they directly work (PFT). In addition to pre- and post-measures, a control group of clients
with broadly similar topographies and duration of challenging behaviour was also identified. The same measures were completed for this group at the same time
points as those for the training group. No staff training
took place for this group and no formal behavioural
assessments were conducted or behaviour support plans
derived from such assessments implemented during this
time. The selection of outcomes for service users as the
focus of interest departs from the majority of work in the
area of staff training in challenging behaviour. The
majority of research to date has evaluated staff training
with respect to staff outcomes such as attribution change
which may mediate staff behaviour with relatively little
work addressing staff behaviour or skills directly (Jahr
1998; Ager & OMay 2001). As such, the selection of service user outcomes lends considerable ecological validity
to the current study and informs us directly as to whether this model of service delivery has beneficial client
outcomes.

Method
Design
A non-randomized matched control group design was
used in this study. Participants were matched on topography of challenging behaviour, duration of challenging
behaviour and gender to reduce pre-treatment differences between groups.

Service users
The target group consisted of service users for
whom staff would complete the training course in

2007 BILD Publications, Journal of Applied Research in Intellectual Disabilities, 20, 615

Journal of Applied Research in Intellectual Disabilities 9

multi-element behaviour support over a 6-month period.

The target group was initially comprised of 37 clients
with challenging behaviours in two different service
locations. This figure was reduced to 30 by the end of
the training period.1 Two staff members did not complete the training because of leaving the service. The
remaining five individuals did not meet the criteria for
completion of the course and are not included here. The
control group of 30 service users consisted of clients also
identified by management as requiring input for challenging behaviour. Members of the control group were
drawn from the same service locations as the target
group. All members of both groups were from the same
ethnic group (see Table 1).

Outcome measures
Challenging behaviour
The frequency, management difficulty and severity of
each behaviour listed in the Checklist for Challenging
Behaviour (CCB) were measured to identify the primary challenging behaviour for each respective individual in both groups. Frequency is scored from 1
(never) to 6 (hourly or more often); management difficulty from 1 (no problem) to 5 (extreme problem); and
severity from 1 (no injury) to 5 (very serious injury).
Reliability of the instrument is reported to be adequate
(Joyce et al. 2001). Scores on frequency, management
difficulty and severity were summed across individual
behaviours. Behaviours were then ranked from the
highest score to the lowest score. The highest ranked
behaviour was identified for each individual and only
this behaviour was used for subsequent comparisons
before and after the 6-month period of training (see
Table 2). For a sub-sample of 26 individuals with challenging behaviour, two staff members completed the
CCB for the primary challenging behaviour independently for the same individual within a 1-week period.
The Spearman rank-order coefficient was used to
determine inter-rater reliability. Scores were summed
for each of the scales and the Spearman statistic was
used to correlate the total scores for frequency, management difficulty and severity. For frequency, the
correlation co-efficient was 0.86 (two-tailed, P < 0.001,
n 26). For management difficulty the correlation
co-efficient was 0.92 (two-tailed, P < 0.01, n 26)
and for severity the correlation co-efficient was 0.80
1

One service was based in a rural setting (n 19) and the other
was based in the suburb of a major metropolitan area (n 11).

Table 1 Demographic and clinical information at time 1

Variable

Target
(n 30)

Mean age (years)

32
Age range (years)
355
Gender
Male
17
Female
13
Level of disability
Mild
6
Moderate
8
Severe
10
Profound
6
Duration of challenging behaviour as per current case
Mean duration (months)
93
Range (months)
6342
Duration of psychiatric medication as
(n 20)
per medication chart at time 1
Mean duration (months)
109
Range (months)
6345
Units of psychiatric medication time 12
5.0
Range
19
Units of psychiatric medication time 2
4.8
Range
17
DSM diagnosis at time 1
No diagnosis
10
Mood disorder
13
Psychosis
3
Autism
3
ADHD
1

Control
(n 30)
39
370
19
11
6
13
11
0
file1
86
12345
(n 16)
149
24312
4.2
113
4.0
110
21
5
1
3
0

Case notes were examined for information regarding approximate onset of challenging behaviour.
2
Unit equivalencies based upon British National Formulary
(2002).

(two-tailed, P < 0.01, n 26). Table 2 presents the primary challenging behaviour as identified in both
groups as per the CBC for the control group and
referral problem for the target group. For the target
group, observation-based measurement was also
undertaken for the highest ranked behaviour on the
CCB as part of the training process.

Psychotropic medication
Determining the amount of medication received by
each client was done using the British National Formulary (BNF) [British Medical Association (BMA) 2002].
The BNF identifies for each medication the amount
that constitutes one therapeutic unit. For example,

2007 BILD Publications, Journal of Applied Research in Intellectual Disabilities, 20, 615

10 Journal of Applied Research in Intellectual Disabilities

Target group challenging

behaviour

Self-injurious behaviour
Exposing body inappropriately
Physical aggression
Verbal and physical aggression
Public masturbation
Lying on the ground
Breaking rules
Loud talking

3
2
14
7
1
1
1
1

Control group challenging

behaviour

Self-injurious behaviour
Exposing body inappropriately
Physical aggression
Verbal and physical aggression
Public masturbation
Stereotyped behaviour
Licking
Stealing
Excessive drinking

4
1
14
5
1
2
1
1
1

100 mg of chlorpromazine (largactil) is one therapeutic

unit and is the equivalent of 1 mg of resperidone (resperdal). The amount of medication per client was calculated by determining the number of units within
each medication across anti-psychotics (typical
and atypical), anti-depressants, mood stabilizers and
anxiolytics using the unit equivalencies provided and
adding them together.

Block one
(3 days)

i.

Assignment
(4 weeks)

Table 2 Challenging behaviours: target

and control groups at time 1

Procedure
Training content
The course comprises nine full days over a 6-month period (see Figure 1). The content of the training course
was adapted from the assessment and intervention protocol developed by the Institute of Applied Behaviour

Block two
(2 days)

Assignment
(4 weeks)

Block three
(1 day)

Functional

ix. Intervention
development

Introduction to
behavioural support

ii.

Environmental

vii. Functionally

accommodation
iii. Skills teaching

Background

equivalent

assessment

assessment

skills teaching

Baseline

viii. Functional

iv. Direct intervention

v.

recording

assessment

Reactive strategies

vi. Behavioural
assessment

Assignment
(4 weeks)

Block four
(1 day)

Assignment
(3 months)

Intervention design

x. Periodic Service

Periodic Service Review

Baseline recording

Review

Quarterly Progress Report

Incident analysis

Block five
(2 days)

Implementation of plan
Case review

Figure 1 Schematic representation of structure and timeframe of person-focused training.

2007 BILD Publications, Journal of Applied Research in Intellectual Disabilities, 20, 615

Journal of Applied Research in Intellectual Disabilities 11

Analysis (LaVigna & Donnellnan 1989). A cornerstone

of the training format is the use of PFT. Participants
completed three written training assignments (i.e. behaviour assessment report, behaviour support plan and
quarterly progress review) with respect to one individual with whom they directly worked who displayed
challenging behaviours and who had been referred for
psychological input. All behaviour support plans specified interventions across four categories: ecological
changes, skills teaching, direct interventions and reactive
strategies. The training format is identical to that
reported by McClean et al. (2005).

Target group: staff training

A training course was conducted within a large residential setting, and two were conducted within a community-based service. Fifteen staff were qualified nurses,
seven were residential care-staff, four were day service
providers, two were intensive support workers and two
were clinical psychologists not associated with the delivery of the training course. The average duration of frontline staff working with the client was 12 months. No
psychological interventions other than those developed
through the training process were implemented across
the 6-month duration of training. Assessments and subsequent behaviour support plans addressed the highest
ranked behaviour on the CCB.

Control group
Either a nurse or a member of care staff who had been
working with the service user for longer than 6 months
completed the CCB. No formal comprehensive behavioural assessments were conducted for this group during the specified training period nor were behaviour
support plans derived from such assessments implemented.

Administration
The CCB was administered on two occasions for both
groups: prior to the commencement of the first workshop (conducting a behaviour assessment), and
6 months later at the end of the fourth workshop (quarterly progress review on the implementation of the
behaviour support plan). For the target group, individualized appropriate observation-based measures of behaviour took place as part of the functional assessment.
Depending on the nature of the target behaviour, these
included event recording, interval recording or fre-

quency of response. In the majority of cases, these were

typically actual frequency data for the target behaviour.
No observational recording took place for the control
group. No data are available with respect to the reliability of observational recordings for the target group. Unit
equivalencies of psychotropic medication were determined for both groups before and after the training period based on the service users file.

Data analysis
Tests for normality were performed on all variables
used in subsequent analysis. Only severity of challenging behaviour was found to be non-normally distributed. A general ancova model using raw scores was
used (with transformed scores for severity) co-varying
scores at time 1 on the outcome variables. This approach
to data analysis was selected as the design did not
involve random allocation to groups at the outset of the
study. As such, there are likely to be minor differences
between the groups at baseline. ancova models take
account of such variance between groups at baseline
and allow a closer examination of the effects of the independent variable whilst accounting for initial differences
if present. Effect sizes were indexed using the partial
eta-squared co-efficient.

Results
No significant differences were observed between the
groups at the start of training (time 1) on frequency,
management difficulty and severity of challenging behaviour. In addition, no significant differences were
observed between the groups on age, gender, duration
of challenging behaviour and duration of psychiatric
medication. Controlling for frequency of challenging
behaviour at time 1, duration of challenging behaviour,
units of medication, gender, level of disability and diagnosis, a significant effect was observed between the two
groups on frequency of challenging behaviour at time 2
as measured by the CCB [F(1, 38) 13.7, P < 0.001;
g2 0.27] (see Figure 2). At time 2, the average mean
score for frequency for the control group was 3.6 and
the average mean score for the intervention group was
2.5. At time 2, the average mean score for management
difficulty for the control group was 3 and the average
mean score for the intervention group was 1.6. Controlling for management difficulty of challenging behaviour
at time 1, duration of challenging behaviour, units of
medication, gender, level of disability and diagnosis, a
significant effect was observed between the two groups

2007 BILD Publications, Journal of Applied Research in Intellectual Disabilities, 20, 615

12 Journal of Applied Research in Intellectual Disabilities

Discussion
The primary finding of the current study is that PFT is
associated with significant reductions for service users
presenting with challenging behaviour and that such
reductions are maintained 6 months after the initial
implementation of behaviour support plans. For twothirds of the target group, the frequency of challenging
behaviour dropped to below 30% of baseline rates after
3 months of implementation of behaviour support plans.
For the remainder, the majority had a rate reduction to
between 70% and 30% of baseline. Taken collectively,

An ancova performed on the untransformed data set indicated a similar result.

These are re-transformed mean scores.

Table 3 Percentage reductions in baseline rates of challenging

behaviour at first quarter
Percentage of
reduction

Number
(n 30)

030% of baseline
3070% of baseline
7080% of baseline
Increase in baseline rate

21
7
1
1

Frequency Time 1

Management Time 2

Frequency Time 2

Severity Time 1

Management Time 1

Severity Time 2

Mean Score

on management difficulty [F(1, 38) 19.4, P < 0.001;

g2 0.34]. As a result of the skew on the severity data,
a transformation using square root was performed on
the data. Controlling for severity of challenging behaviour at time 1, duration of challenging behaviour, units
of medication, gender, level of disability and diagnosis,
a significant effect was observed between the two
groups [F(1, 38) 9.7, P < 0.005; g2 0.20]2 on severity.
At time 1, the average mean score for severity for the
control group was 1.6 and the average mean score for
the intervention group was 1.1.3
For the target group, rates of target behaviour based
on observational measures reduced significantly from
baseline to first quarter (i.e. 3 months after the implementation of the behaviour support plan; t 5.15,
d.f. 29, P < 0.00). The average reduction in frequency
of behaviour across this period was to 24% of baseline
rates for 29 of the 30 service users with challenging
behaviour. The frequency of challenging behaviour was
reduced to below 30% for 21 service users (see Table 3).
Additional data were available at second quarter (i.e.
6 months after implementation of behaviour support
plan) for 19 individuals who had attended two of the
training courses. Rates of challenging behaviour
dropped to 18% of initial baseline at first quarter, and to
11% at second quarter (see Figure 3).
For both target and control groups, there was no significant reduction in the overall number of units of
medication prescribed (control group, t )0.80,
d.f. 28, P < 0.43; target group, t 1.2, d.f. 28,
P < 0.22). There was no significant reduction in the
number of clients being taken off medication for either
group.

0
Target

Control

GROUP
Figure 2 Mean scores on CBC by group.

there was a reduction to 22% of baseline for the target

group at first quarter and a further reduction to 11% for
a sample of 19 service users at the second quarter.
While direct observational recording did not take
place for the control group, frequency of challenging
behaviours as reported on the CCB did not alter significantly throughout the equivalent time period. This finding is in general agreement with previous research
indicating that in the absence of appropriate intervention, challenging behaviours remain chronic (Thompson
& Reid 2002). In contrast, a significant difference was
observed for the target group on all three measures of
the CCB. In interpreting these results, it is important to
bear in mind that there was no significant difference at
the outset of the training period on CCB measures of
frequency, management difficulty and severity between
the target and control group. Furthermore, there was no
significant reduction in the actual number of clients on

2007 BILD Publications, Journal of Applied Research in Intellectual Disabilities, 20, 615

Journal of Applied Research in Intellectual Disabilities 13

25

Mean rate

20

15

10

0
Baseline

1st quarter

2nd quarter

Figure 3 Rate reduction in challenging behaviour.

psychotropic medication or in the relative number of

units of psychotropic medication prescribed. While there
was a higher number of clients in the target group with
a formal mental health diagnosis, all had been on psychotropic medication for at least 6 months prior to the
training course. Therefore, the effects of such medication
would have most likely had therapeutic effects by the
commencement of the training course. However, medication changes in the 6 months preceding the training
course were not tracked. In the light of both of these
observations, reductions in frequency of challenging
behaviour and maintenance of such reductions can be
attributed to PFT.
These results are further consolidated in the light of
the ancova results. When duration of challenging behaviour, units of psychotropic medication, gender, level of
disability and diagnosis are controlled for at the start of
the training period, there is a significant difference
between the groups at the end of the training period on
the CCB measures of frequency, management difficulty
and severity. Furthermore, the effect sizes for these variables was substantial with figures of 27%, 34% and 20%
respectively.
While the behaviour support plans developed through
PFT were effective in supporting individuals with challenging behaviour both in this study and those in
McClean et al. (2005), it remains unclear what ingredients
of these behaviour support plans are most effective.
Although outside the scope of the present research,
future studies may consider coding interventions into the
four general categories (ecological/antecedent change,
skills teaching, direct interventions/motivation and

reactive interventions) and subsequently tracking the

daily/weekly implementation of interventions and determine their respective relationships to defined outcomes.
These results are largely in line with those of McClean
et al. (2005) on PFT as an effective model of service
delivery. Specifically, they reported that training staff to
conduct functional assessments and to design and
implement behaviour support plans was associated with
significant improvements in 77% of service users presenting with challenging behaviour. Using the same criteria for improvement (i.e. reductions to below 30% of
baseline), improvements were reported for almost 70%
of the target group. These findings also lend support to
the argument by McClean et al. (2005) that in services
where challenging behaviours are highly prevalent, consultation may be a far more expeditious model of service delivery than specialist intervention.
The findings should however be interpreted within
the light of certain methodological considerations. First,
though a control group was utilized in this study, allocation to groups was not randomized which would have
strengthened the findings. However, in clinical settings
with pressing demands for intervention from management and care-staff it is not always possible to meet
such criteria. Second, there are issues with respect to the
use of the CCB to detect behaviour change and its usage
in this study. There is limited research available on the
effectiveness of the CCB in detecting behaviour change
across time and perhaps an alternative instrument
would have been more appropriate. To date, however,
no extensive review has been conducted on this issue. A
further difficulty with the CCB is that it was used in a
non-blind fashion (i.e. completed by the person in the
intervention condition), which is a methodological
weakness of most studies relying on self-report measures (Sturmey 2002). Ideally, a second staff member
could be identified for each service user in the target
group and they could complete pre- and post-measures
without undergoing training. Although subsequent comparison would be interesting, it is unlikely whether this
would meet the criterion for a blind rating as support
plans are developed in consultation with the entire team
and therefore all care staff would be familiar with the
support plan. A further measurement issue is the
absence of an inter-observer agreement procedure for
the target group with respect to observation based
measures. As a result, caution must be exercised in the
interpretation of results in this area.
An additional limitation concerns generalization.
Many clients presenting with challenging behaviour
do so with more than one topography or type. Many

2007 BILD Publications, Journal of Applied Research in Intellectual Disabilities, 20, 615

14 Journal of Applied Research in Intellectual Disabilities

service users in the target group presented with several

challenging behaviours and it possible that reductions in
the frequency, management difficulty or severity of challenging behaviours other than that directly targeted may
have may have taken place. However, this was not
explored in the current study but should be a focus of
future research investigating PFT.
The accuracy of some of the demographic information
must also be questioned. There was a substantial discrepancy across files in respect of information available
for service users in both groups. In particular, existing
psychiatric diagnosis for clients was drawn from available files and not based upon using a recognized and
accurate diagnostic assessment template. All diagnoses
on file were clinician-based. Future work should employ
a standardized assessment template across all clients
administered by highly experienced practitioners. Furthermore, in this study, the use of psychotropic medication was tracked using the method of unit equivalency
from the BNF. Although the number of units across
both groups did not change significantly across the duration of PFT, it is possible that changes within the total
number of units occurred in some cases. As such, the
use of combined unit equivalency alone is a somewhat
crude measure to track the use of psychotropic medication. A more accurate method would involve the tracking of unit equivalencies within categories of
psychotropic medications such as antidepressants across
time.
The role of supervisory arrangements and specifically
the frequency of such arrangements remains unclear in
the current study. Previous research clearly indicates
that a critical factor in the maintenance of staff behaviour post-training is supervisor feedback (Parsons &
Reid 1995). Ager & OMay (2001) argue that the organizational factors such as the facilitation of effective
supervisory arrangements are critical in the maintenance
of interventions although this appears to require the
deployment of consultants whose continued input
appeared to be necessary for the behaviour changes of
staff members to be retained at high levels (Harchik
et al. 1992). Equally important is the issue of quality control in respect of services and is considered by some as
a necessary surveillance system of the quality of contexts and interactions in the lives of those with disabilities.
They further propose that the clear challenge is to
establish interventions and structures which foster reappraisal of staff assumptions and expectancies regarding
behaviourally based interventions. It would appear that
PFT may go some way to achieving this end.

Acknowledgments
The authors would like to thank all staff who participated in the study and also Dr David Hevey of the
School of Psychology for expert statistical advice.

Correspondence
Any correspondence should be directed to Ian Grey,
School of Psychology, Trinity College, Dublin, Ireland
(e-mail: igrey@tcd.ie).

References
Ager A. & O May F. (2001) Issues in the definition and implementation of best practice for staff delivery of interventions for challenging behaviour. Journal of Intellectual &
Developmental Disability 26, 243256.
Anderson D. J., Lakin K., Hill B. K. & Chen T. (1992) Social
integration of older persons with mental retardation in residential facilities. American Journal on Mental Retardation 96,
488501.
British Medical Association (BMA) (2002) British National Formulary. British Medical Association and Royal Pharmaceutical
Society of Great Britain, London.
British Psychological Society (2004) Psychological interventions for
severely challenging behaviours shown by people with learning
disabilities clinical practice guidelines. St. Andrews House,
Leicester.
Bruininks R., Hill B. K. & Morreau L. E. (1988) Prevalence and
implications of maladaptive behaviours and dual diagnosis
in residential settings. In Mental Retardation and Mental Health:
Classification, Diagnosis, Treatment Services (eds J. A. Stark, F. J.
Menolascino, M. H. Albarelli & V. C. Gray), pp. 147173.
Springer-Verlag, New York.
Carr E. G., Horner R. H., Turnbull A. P., Marquis J. G., McLauglin D. M., McAtee M. L., Smith C. E., Ryan K., Ruef M.
B., Doolabh A. & Braddock D. (1999) Positive Behavior Support
for People with Developmental Disabilities: A Research Synthesis.
American Association on Mental Retardation, Washington,
DC.
Carr E. G., Dunlap G., Horner R. H., Koegel R. L., Turnbull A.
P., Sailor W., Anderson J. L., Albin R. W., Koegel L. & Fox E.
(2002) Positive behavior support: Evolution of an applied
science. Journal of Positive Behavior Interventions 4, 416.
Emerson E. (2001) Challenging Behaviour: Analysis and Intervention in People with Severe Intellectual Disabilities 2nd edn. Cambridge University Press, Cambridge.
Emerson E. & Bromley J. (1995) The form and function of challenging behaviours. Journal of Intellectual Disability Research
39, 388398.
Emerson E. & Emerson C. (1987) Barriers to the effective implementation habilitative behavioural programs in an institutional setting. Mental Retardation 25, 101106.

2007 BILD Publications, Journal of Applied Research in Intellectual Disabilities, 20, 615

Journal of Applied Research in Intellectual Disabilities 15

Emerson E. & Forrest J. (1996) Community support teams for

people with learning disabilities and challenging behaviour.
Journal of Mental Health 5, 395405.
Feldman M., Atkinson L., Foti-Gervais L. & Condillac R. (2004)
Formal versus informal interventions for challenging behaviour in persons with intellectual disabilities. Journal of Intellectual Disability Research 48, 6068.
Grey I. M. & Hastings R. (2005) Evidence based practice in the
treatment of behaviour disorders in intellectual disability.
Current Opinion in Psychiatry 18, 469475.
Harchik A. E., Sherman J. A., Sheldon J. B. & Strouse M. C.
(1992) Ongoing consultation as a method of improving performance of staff members in a group home. Journal of
Applied Behaviour Analysis 25, 599610.
Harper D. C. & Wadsworth J. S. (1993) Behavioural problems
and medication utilization. Mental Retardation 31, 97103.
Jahr E. (1998) Current issues in staff training. Research in Developmental Disabilities 19, 7387.
Joyce T., Ditchfield H. & Harris P. (2001) Challenging behaviour
in community services. Journal of Intellectual Disability Research
45, 130138.
Knoster T., Anderson J., Carr E., Dunlap G. & Horner R. (2003)
Emerging challenges and oppertunities. Journal of Positive
Behavior Interventions 5, 183186.
Larson S. (1991) Quality of life for people with challenging
behaviour living in community settings. Impact 4, 45.
LaVigna G. W. & Donnellnan A. M. (1989) Behavior Assessment
and Intervention Guide. Institute for Applied Behavior Analysis
Press, Los Angeles, CA.
LaVigna G. W., Willis T. J., Shaull J. F., Abedi M. & Sweitzer
M. (1994) The Periodic Service Review: A Total Quality Assurance
System for Human Services & Education. Paul Brookes Publishing, Baltimore.
McClean B. & Halliday A. (1999) Positive futures planning: a
different kind of service. Frontline 40, 2327.
McClean B. & Walsh P. (1995a) An organisational response to
challenging behaviour. Positive Practices 1, 38.
McClean B. & Walsh P. (1995b) Positive programming an
organisational response to challenging behaviour. Positive
Practices 1, 38.
McClean B., Dench C., Grey I. M., Shanrahan S., Fitzsimmons
E. M., Hendler J. & Corrigan M. (2005) Outcomes of person

focused training: a model for delivering behavioural supports

to individuals with challenging behaviours. Journal of Intellectual Disability Research 49, 340353.
McGillivray J. & McCabe M. P. (2004) Pharmacological management of challenging behavior of individuals with intellectual
disability. Research in Developmental Disabilities 25, 523537.
Parsons M. B. & Reid D. H. (1995) Training residential supervisors to provide feedback for maintaining staff teaching skills
with people who have severe disabilities. Journal of Applied
Behavior Analysis 28, 317322.
Robertson J., Emerson E., Pinkney L., Caesar E., Felce D., Meek
A., Carr D., Lowe K., Knapp M. & Hallam A. (2005) Treatment and management of challenging behaviours in congregate and noncongregate community-based supported
accommodation. Journal of Intellectual Disability Research 49,
6372.
Singh A. N., Matson J. L. & Cooper C. L. (2005) The use of risperidone among individuals with mental retardation: clinically supported or not. Research in Developmental Disabilities
26, 203218.
Snell M., Voorhees M. & Chen L. (2005) Team involvement
in assessment-based interventions with problem behaviour.
Journal of Positive Behavior Interventions 7, 140152.
Sprague J. R., Flannery B., ONeill R. & Baker D. J. (1996)
Effective Behavioural Consultation: Supporting the Implementation of Positive Behaviour Support Plans for Persons
with Severe Challenging Behaviours. Specialised Training
Program, Eugene, OR, USA.
Stancliffe R. J., Hayden M. F. & Lakin K. C. (1999) Effectiveness
of challenging behaviour IHP objectives in residential settings: a longitudinal study. Mental Retardation 37, 483493.
Sturmey P. (2002) Mental retardation and concurrent psychiatric disorder: assessment and treatment. Current Opinion in
Psychiatry 15, 489495.
Thompson C. L. & Reid A. (2002) Behavioural symptoms
among people with severe and profound intellectual disabilities: a 26-year follow-up study. British Journal of Psychiatry
181, 6771.
Watson A., Rutterford N. A., Shortland D., Williamson N. &
Alderman N. (2001) Reduction of chronic aggressive
behaviour ten years after brain injury. Brain Injury 15, 1003
1015.

2007 BILD Publications, Journal of Applied Research in Intellectual Disabilities, 20, 615