PBS & ABA research —campaign edition (Part 2)
Ann Memmott returns for Part 2 of the AGAINST PBS & ABA research roundup blog, in which Ann explores further related research papers and existing resources.
Part 2 of this research roundup takes a similar format to part 1. The research papers included are not an exhaustive list, but serve to share an insight into Positive Behaviour Support (PBS) and Applied Behaviour Analysis (ABA). The papers include thoughts and experiences from various Neurodivergent advocates, and include suggestions from PBS leaders about how the industry might do better.
What do PBS teams think of Neurodiversity Paradigms?
The International Journal of Positive Behaviour Support has produced their Spring 2025 focus on PBS and neurodiversity.
Bambara et al,. (2025), in their Reflections paper, note the surprise of the PBS industry that neurodiversity supporters are concerned about PBS. “Autistic people and their families need to trust that PBS leaders…will centre supports around their needs…”, they write. As this is meant to be an evidence-based process, one would hope that trust alone was not required.
There is also the belief that neurodiversity-paradigm-based researchers and the Autistic communities simply do not understand PBS, but, this is not evidenced by the team.
The evidence within the paper by Quinn (2025) is rather dismissed as not representative of PBS, and otherwise is not considered. The paper does not mention restraint, other than one brief mention in the context of Quinn’s experience. Most PBS teams are given training on restraint methods (physical, psychological, chemical, use of seclusion, mechanical and otherwise), as per this example of CQC guidance.
The teams generally implement a wide variety of restraints on individuals in their care. Yet, the overview paper by Bambara and team does not mention restraints, which seems an odd omission.
The report ‘An evaluation of the implementation of the “Restraint Reduction Network (RRN) Training Standards” in mental health and learning disability settings’ details some stark findings, showing that in 2017, 22,000 incidents of restraint on Autistic people and people with learning disabilities were reported in mental health wards, but this rose to 38,000 incidents by 2020. If PBS is working, one wonders how this increase is occurring.
Bambara, Duenas and Dwyer (2025) have produced a paper within this Journal issue further considering the matter of PBS and neurodiversity, and again making clear that PBS is an “ABA based approach”. One of the three authors is Autistic and not part of the PBS/ABA industries. This reiterates the points made in the overview paper, but states that, “no one assessment, intervention or problem solving approach is [solely] a PBS approach”. This leaves us with the problem of defining a service where seemingly almost anything could be called PBS. The paper outlines a number of ambitious targets to better align PBS with neurodiversity best practice, which is commendable, but in Table 1 adds in Cognitive-Behavioural Approaches and Acceptance and Commitment Therapy (ACT). These approaches are themselves considered problematic by many in the neurodiversity fields. For example, ACT research measures success on whether Autistic people appear less Autistic to others after the process; see Pahnke et al., (2023). Such potential masking of Autism may put people at risk of problematic outcomes such as increased suicidality, depression and anxiety. It is however good to see that the PBS industry is hoping to monitor short and long term adverse events after PBS/ ABA interventions, which is not routinely done at present. The team note that the current ABA ethics code does not define which goals should be selected for ‘intervention’, leaving teams to do as they please, and the assessment of quality of life has rarely occurred, despite this being the core aim of PBS. Of deep concern is the finding that out of 174 PBS/ ABA studies involving Autistic students, only five asked the Autistic people for their views. The paper also notes that ABA/ PBS has generally not considered individual’s views as particularly relevant, as these are allegedly not measurable, therefore unscientific. They recommend rethinking this. A good plan! Again, one notes that the paper is silent on the subject of restraints being applied to individuals in the care of PBS teams.
There is a lot of reflective thinking within the Pahnke et al. paper and I would recommend it as a good starting point for further exploration of the topic.
Kilgallon and team consider whether PBS is consistent with the neurodiversity movement. In their view, there is much to do, including better alignment with human rights, a better focus on dignity and self-worth, autonomy and equality, a much better set of processes around establishing meaningful consent/ assent to procedures, and very much better communication with Autistic people and groups. They also note there is little current focus on ensuring communication methods are available for those who are nonspeaking or semi-speaking (‘mouth-words’).
Quinn (2025), is Autistic and has experienced PBS, and various restraint processes from PBS teams. Quinn notes how the PBS recording systems encourage a ‘detached outsider’' approach that is at odds with viewing individuals as fellow humans. Whilst Quinn is clear that various teams can show care and support, the process of PBS is not clearly linked to successful outcomes for individuals. There is certainly truth, in my view, to the assertion that, “...attempting to enhance people’s quality of life in environments where people are denied their liberty will probably never succeed”. Quinn notes that behavioural intervention processes may lead to a, “...loss of trust in one’s own natural experiencing, desires and imagination.” Quinn asks for therapeutic love to be at the forefront of care, an approach that is free from judgement of right and wrong, but seeks to understand pain, fear and distress and respond with a deep humanity. “Love is an active, not passive endeavour.”
Bambara, L. M., Bowring, D., Lucyshyn, J. M., & MacDonald, A. (2025). Reflections on the special issue of positive behaviour support and neurodiversity: moving towards consensus. International Journal of Positive Behavioural Support, 15(1), 52-55. https://www.ingentaconnect.com/contentone/bild/ijpbs/2025/00000015/00000001/art00008
Bambara, L. M., Dueñas, A. D., & Dwyer, P. (2025). Positive behaviour support and the neurodiversity perspective. International Journal of Positive Behavioural Support, 15(1), 4-22. https://www.ingentaconnect.com/contentone/bild/ijpbs/2025/00000015/00000001/art00003
Kilgallon, E., Daou, N., & Gillespie-Lynch, K. (2025). In what ways is positive behaviour support consistent or inconsistent with the principles of the neurodiversity movement? It's complicated. International Journal of Positive Behavioural Support, 15(1), 28-34. https://www.ingentaconnect.com/contentone/bild/ijpbs/2025/00000015/00000001/art00005
Pahnke, J., Jansson-Fröjmark, M., Andersson, G., Bjureberg, J., Jokinen, J., Bohman, B., & Lundgren, T. (2023). Acceptance and commitment therapy for autistic adults: A randomized controlled pilot study in a psychiatric outpatient setting. Autism, 27(5), 1461-1476. https://journals.sagepub.com/doi/pdf/10.1177/13623613221140749
Quinn, A. (2025). Relationships of concern: the perils of the progress paradox in positive behavioural support. International Journal of Positive Behavioural Support, 15(1), 35-44. https://www.ingentaconnect.com/contentone/bild/ijpbs/2025/00000015/00000001/art00006
PBS and Quality of Life
We will recall that a key ‘selling point’ of PBS is the assertion that it improves quality of life.
Whincup and team (2024) took a look at the outcomes from PBS in mental health settings. “No consistent measure of quality of life was used across settings.”
The paper by Gore and team (2022) discusses quality of life outcomes. They note that Bowring & team (2020) reported a Quality of Life improvement after 85 people with a learning disability and/or a diagnosis of Autism were in a PBS setting. However, that team had invented their own short measure of Quality of Life, otherwise unvalidated, only asked other people whether the person’s life quality was better rather than asking the person themselves, and did no long term follow-up on life quality. Gore and team also note the findings of MacDonald & team (2018), discovering that staff training in PBS made no difference to quality of life for the individuals receiving PBS.
Bruinsma considered quality of life outcomes for 123 people with intellectual disabilities who were in PBS settings, using the Personal Outcome Scale as a measure, and only asking the staff. 46 people made it to the end of the research project. The highest possible score is 24, from eight items of a maximum three points each. Average scores increased from 12.63 to 13.7 on ‘personal development’, and decreased from 14.38 to 12.54 on ‘social inclusion’. Ultimately there was no meaningful change, and on some measures there was a decrease in quality of life.
One would assume that there must be a substantial base of research proving that the individuals have affirmed their lives are better after undergoing PBS, but such evidence seems elusive.
Bowring, DL, Totsika, V, Hastings, RP and Toogood, S (2020), ‘Outcomes from a community-based positive behavioural support team for children and adults with developmental disabilities’, Journal of Applied Research in Intellectual Disabilities, 33(2), 193–203. https://onlinelibrary.wiley.com/doi/abs/10.1111/jar.12660
Bruinsma, E. (2025). Positive behaviour support in Dutch care settings: a multifaceted approach to managing challenging behaviours of adults with intellectual disabilities: Effectiveness, implementation and adherence requirements, and quality of life outcomes. https://research.rug.nl/en/publications/positive-behaviour-support-in-dutch-care-settings-a-multifaceted-
Gore, N. J., Sapiets, S. J., Denne, L. D., Hastings, R. P., Toogood, S., MacDonald, A., ... & Williams, D. (2022). Positive behavioural support in the UK: a state of the nation report. International Journal of Positive Behavioural Support, 12(1), i-46. https://www.ingentaconnect.com/contentone/bild/ijpbs/2022/00000012/a00101s1/art00001
MacDonald, A., McGill, P., & Murphy, G. (2018). An evaluation of staff training in positive behavioural support. Journal of Applied Research in Intellectual Disabilities, 31(6), 1046-1061.
Whincup, R., & Tunnicliffe, P. (2024). The use of positive behavioural support in mental health settings: a systematic review of the literature. International Journal of Positive Behavioural Support, 14(1), 18-29. https://www.ingentaconnect.com/content/bild/ijpbs/2024/00000014/00000001/art00004
PBS and ‘Challenging Behaviour’
Much ‘Challenging Behaviour’ in the PBS industries is measured using the Aberrant Behaviour Checklist (ABC) Irritability Scale. This requires teams to consider if the person is ‘whiny’ or ‘cries over minor annoyances’; whether their ‘mood changes quickly’, ‘cries..inappropriately’, is ‘depressed’ or has an Autistic brain event (meltdown, which they describe as a ‘tantrum’). It is, in my view, a dehumanising list that fails to understand Autistic communication, brain events or distress, and portrays all of it as childish ‘behaviour’ that is to be ‘reduced’, rather than very human emotions to be understood in partnership with the person.
For example:
Clare and team (2024) examine the outcomes from using PBS with 16 Autistic males with a variety of diagnoses, including Autism. The team examined the incidence of violence and aggression before and after six months of PBS intervention. There was no significant change. They recommend more research.
Hassiotis & team (2018) examined the results of PBS on over 200 individuals. It made no difference to rates of ‘challenging behaviour’ as measured using the ABC Irritability Scale.
Bruinsma and team (2024) likewise hoped that PBS would reduce ‘challenging behaviour’ as measured by the ABC Irritability Scale, testing this on 123 individuals and finding that, " On Irritability no significant differences were observed …at [Time point] 3”.
Bruinsma, E., van den Hoofdakker, B. J., Hoekstra, P. J., de Kuijper, G. M., & de Bildt, A. A. (2024). Effects of positive behaviour support delivered by direct staff on challenging behaviours and quality of life of adults with intellectual disabilities: A multicentre cluster‐controlled trial. Journal of Applied Research in Intellectual Disabilities, 37(1), e13164.
Clare, C. Evaluating the Use of Positive Behaviour Support Plans in a High Support Rehabilitation Unit for Adult Males. Issue no., 13. https://www.cygnetgroup.com/wp-content/uploads/2024/09/CYG-634-The-Cygnet-Journal_Issue-1_V9_Web.pdf#page=13
Hassiotis, A., Poppe, M., Strydom, A., Vickerstaff, V., Hall, I. S., Crabtree, J., ... & Crawford, M. J. (2018). Clinical outcomes of staff training in positive behaviour support to reduce challenging behaviour in adults with intellectual disability: cluster randomised controlled trial. The British Journal of Psychiatry, 212(3), 161-168.
PBS and human rights
The Irish Joint Committee on Disability Matters (2023) set out a report on aligning disability services with the United Nations Convention on the Rights of Persons with Disabilities.
The Committee are aware that positive behavioural support (PBS) which is reported as being consistent with human rights as documented in the UNCRPD and places a person's behaviour within an ecological context is considered by people with disabilities, activists, and advocates, to be founded on the same underlying approach as ABA. In this regard, there is evidence to suggest that PBS risks the same harms as ABA and there is significant opposition to the use of any of these related behaviourism-based therapies by the autistic community and their representative 60…, the lived experience of people with disabilities is a priority of the Committee to build awareness of the issues that people with disabilities face in their daily lives. In response to this lived experience the Committee are aware how behavioural interventionist therapies such as PBS, ABA are medicalised and differ crucially from the principles underlying Speech and Language Therapy (SLT), and Occupational Therapy (OT). Behavioural interventionist therapies are ultimately founded on modifying disabled people's behaviour to meet goals decided by others; often to conform more closely with neurotypical communication, behaviour and/or norms and therefore the Committee believe cannot uphold the UNCRPD principles of autonomy, dignity, right to identity and freedom from non-consensual or degrading treatment.
Elements of the wider subject of the care and treatment of mental health patients in hospital settings is considered in the rebuttal paper by Quinn and team (2025), who note that many are subjected to isolation against their will, and against their human rights. Again, the PBS industry is effectively ‘in charge’ of such implementation, and it would be good to see some reflection from the PBS research teams on how this enforced isolation fits with notions of positive and supportive care.
The Australian Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability produced a substantial report on restrictive interventions and the role of PBS (Spivakovsky et al., 2023). Pages 8-9 of the report detail considerable concerns about PBS, including the lack of good evidence of it working, the lack of evidence of staff training in PBS having led to any better outcomes for patients, the generally poor quality of PBS plans for individuals, and the lack of understanding of what actually made a difference to outcomes.
In studies that provided details about the nature of the ‘intervention’ that took place to produce a positive outcome, what appears to have changed is the quality of the environment and service being provided to the person with disability. Positive outcomes appear to occur for people with disability when: (a) staff are nonconfrontational and consistent in their communication with the person with disability; (b) staff do not impinge on the autonomy of the person with disability; (c) people with disability are enabled to participate in meaningful activities of their choosing; and (d) the wishes of the person with disability are listened to and acted upon. Such findings are consistent with the understanding that perceived ‘behaviours of concern’ are distress, protest and resistance made in a context of maladaptive ‘environments of concern’.
Quinn, A., Cavanagh, D. E., Kilcoyne, J., Haines-Delmont, A., Ryan, S., Lodge, K.-M., … Pavlopoulou, G. (2025). Long-term segregation and seclusion for people with an intellectual disability and/or autism in hospitals: critique of the current state of affairs: commentary, Quinn et al. The British Journal of Psychiatry, 1–3. doi:10.1192/bjp.2025.53
Spivakovsky, C., Steele, L., & Wadiwel, D. (2023). Restrictive practices: A pathway to elimination. Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability. https://disability.royalcommission.gov.au/publications/restrictive-practices-pathway-elimination
What is an alternative approach?
Part 1 and Part 2 of this review of PBS sets out some of the puzzling, and sometimes alarming, background of the situation on mental health wards, and many newer research findings that likewise raise concerns as well as making recommendations.
Perhaps a wider question should be ‘Why PBS?’ Behaviourism is only one of many psychological theories. Could it be that behaviourism simply is not the answer to improving the lives of Autistic people and people with a learning disability?
Rather than focus on reforming the PBS industries, teams have worked hard on alternative frameworks and principles for supporting mental health and wellbeing, in collaboration with Autistic people.
The work by McGreevy & team sets out an example of different and inclusive approaches, and worth considering.
This neuroinclusive approach creates a culture of respect, honours the sovereignty of the person, prioritizes personalization of care based on collaborative decision-making, and enables practitioners to support well-being from an existential, humanistic view, grounded in acceptance of Autistic diversity of being. Without a fundamental shift toward such Neurodivergence-affirming support with practitioners being willing to transform their understanding, real progress cannot happen to prevent poor mental health outcomes for autistic people across the lifespan. This shift is needed to change practice across research, clinical, and educational contexts.
Examples of alternative Neurodivergent frameworks for supporting people in mental health settings include:
Autistic SPACE
Developed by clinicians and focusing on Sensory needs, Predictability, Acceptance, Communication and EmpathyNEST
Developed by Neurodivergent team members and based on work by organisations such as Studio III. The approach is founded on the four principles of Nurture, Empathising, Sharing concerns, and TeamworkNational Autistic Taskforce “Quality Care for Autistic People”
A report setting out extensive information based on the following approaches and principles:
Respect and promote autonomy
Support communication effectively throughout the lifespan
Provide care which is Autistic person-centred
Tackle environmental and other stressors
Remove barriers to access
Fight stigma and discrimination
Recognise behaviour as distress
Ensure better transitions
Ensure ongoing, practical, Autism-specific staff training
Accept difference and support positive Autistic identity
Doherty, M., McCowan, S., & Shaw, S. C. (2023). Autistic SPACE: a novel framework for meeting the needs of autistic people in healthcare settings. British Journal of Hospital Medicine, 84(4), 1-9. https://www.magonlinelibrary.com/doi/full/10.12968/hmed.2023.0006
McGreevy, E., Quinn, A., Law, R., Botha, M., Evans, M., Rose, K., ... & Pavlopoulou, G. (2024). An experience sensitive approach to care with and for autistic children and young people in clinical services. Journal of Humanistic Psychology, 00221678241232442. https://journals.sagepub.com/doi/full/10.1177/00221678241232442
Autistic SPACE https://www.magonlinelibrary.com/doi/full/10.12968/hmed.2023.0006
NEST https://www.spectrumgaming.net/the-nest-approach
National Autistic Taskforce Quality Care for Autistic People https://nationalautistictaskforce.org.uk/wp-content/uploads/RC791_NAT_Guide_to_Quality_Online.pdf
