What is positive behaviour support (PBS)? A manager's guide for learning disability services

Positive behaviour support (PBS) is a way of supporting people with a learning disability, and autistic people, whose behaviour challenges: you work out why the behaviour happens, then change the person's support and surroundings so they have a better life and need the behaviour less. A PBS plan writes that down for one person. It says what the behaviour seems to be telling you, what helps day to day, the early signs to watch for and what to do then, the safest and least restrictive response if the behaviour still happens, and who is responsible for the plan and when it's reviewed.

I was a registered manager for 15 years, running care homes, including learning disability homes. So this guide starts with how PBS worked in the homes I ran: who wrote the plan, why it kept changing between reviews, what made plans fail and what we looked for when we reviewed them. After that comes what the official frameworks say, including the "how many steps" question, how PBS relates to ABA, the criticisms of it, and where it sits with restrictive practice, STOMP and CQC's guidance.

What PBS means in plain terms

The UK key messages on PBS say behaviour that challenges always happens for a reason, and it may be the person's only way of communicating an unmet need. Pain, noise, boredom, fear, a change in routine or not being understood can all sit behind it. PBS asks staff to find that reason and meet the need in a better way, rather than just stopping the behaviour.

Skills for Care describes PBS as understanding the reasons behind the behaviour, such as the person's life history, physical health and emotional needs. The PBS Competence Framework calls it a multicomponent framework rather than a single therapy, built on person-centred values and behavioural science, and done with the person rather than to them. BILD's Centre for the Advancement of PBS describes it as an evidence-informed, human rights-based framework, and says good practice keeps evolving.

You'll hear different words for the same thing: behaviour that challenges, behaviours of concern, distressed behaviour. CQC's guidance for learning disability and autism services talks about people "communicating a need, expressing their feelings or an emotional reaction", so that staff focus on what the person is going through. The words matter, because they shape how staff see the person.

How we wrote a PBS plan

In the homes I ran, a PBS plan was written by three people sitting down together: the service user, their key worker and the team leader.

The key worker was dedicated to that service user. They understood them fully: their trigger factors, their behaviour, what they liked and what they didn't. They were the one who spent the most time with them.

The team leader was there to oversee everything, and got the handover of it all. Between the three of them, that's how we formulated the plan.

The official guidance builds on the same idea. NICE guideline NG11 says the plan should rest on a shared understanding of what the behaviour is for, and should name the people who deliver it and one person who coordinates it. The PBS Competence Framework says the person's key carers, and the person themselves whenever possible, should be fully involved in the assessment. For behaviour that is severe or complex, or isn't responding to the plan, NICE recommends a multidisciplinary assessment with specialist input. Ask your community learning disability team for specialist input where you need it.

NICE NG11 (recommendation 1.6.1) says the plan should include:

• proactive strategies that improve the person's quality of life and change the environment;
• teaching a new skill that does the same job as the behaviour;
• ways to calm the person at the first signs of distress;
• reactive strategies for when the behaviour can't be prevented.

Some services, including some NHS trusts, set the plan out in colours so staff can find the right section fast. Others use green, amber and red only and treat post-incident support as a separate section:

For a full worked plan, section by section, see our positive behaviour support plan example.

Monthly, but rolling

We assessed every plan every month, every 30 days. But it was rolling. It didn't sit untouched between reviews.

If we knew a service user had particular trigger factors, such as a change in routine or a new member of staff, we monitored them really closely: their behaviour, how things were changing, any change in the dynamics.

The key worker would update the team leader, something like: "since the new member of staff started, they've been unsettled." The team leader updated the behaviour support plan, and the update was passed on to the staff.

When it was one new member of staff unsettling someone, we'd do one of two things. We'd alternate the shifts, so there wasn't too much going on for the person at once. Or we'd encourage the friendship and help a new relationship build.

That's what the guidance means by a live plan. The PBS Competence Framework lists treating the behaviour support plan as a live document among its competences, and says a repeat assessment should always follow any change in how a person's behaviour presents. For a new plan, NICE NG11 sets a tighter pace: review it fortnightly for the first two months and monthly after that, particularly if the behaviour or the use of restrictive interventions increases or the person's quality of life falls.

Why PBS plans fail

A PBS plan fails if staff don't follow it. It also fails if the service user becomes highly unsettled.

A change in routine can do it. Here's the kind of thing I mean. Everything is going normally, then a family member decides they want to take the service user out every three days. The plan wasn't designed for that. Out of the home, the service user is away from their usual routine and surroundings, and we didn't know where they were going.

Wanting that time together is fair, and it matters. But it can unsettle the person. So either the plan has to be rewritten and amended, or we talk to the family: "since the new routine started, they've been having these issues."

The guidance treats "staff follow the plan" as something to check, not assume. NICE NG11 says the plan should be supported by data showing it is being carried out accurately, and the Competence Framework lists monitoring how the plan is delivered as a competence in its own right. In practice that means watching a shift, asking staff to talk you through one person's early signs, and making sure bank and agency staff know the plan before they work with the person alone.

How we reviewed a plan

We reviewed every plan every 30 days. Generally we did it with the family or next of kin, and we took into account what the GP said, what the psychologist said, the person's medicines and any new members of staff. We took everything into consideration.

What we looked for:

• changes in behaviour, including positive behaviour and new behaviours;
• new trigger factors;
• the positive side. How has the service user improved, and what caused it? Was it a new routine? The diet? The music? Maybe they like being social, and going out more often has helped. Sometimes it's the service user themselves.

Service users are often very fond of one particular member of staff. Swap that person out, for whatever reason, and it upsets the dynamics. That's why we kept the same buddy and key worker system.

National guidance backs a wide review. Positive and proactive care (Department of Health, 2014) says people who use services, their families and carers must be involved in planning, reviewing and evaluating their care and support. NICE NG11 asks for the plan to be monitored with objective data collected continuously, not just on review day. That's where ABC charts come in.

Getting ABC charts filled in properly

An ABC chart records the antecedent (what happened just before), the behaviour (what the person did, described plainly) and the consequence (what happened straight after, including what staff did). NICE NG11 lists direct observation and structured record keeping among the ways to understand behaviour. It also asks for a baseline and repeated measurements, so you can see whether things are changing.

Charts are only as good as what goes on them. These habits help:

• Write it soon, once everyone is safe, while the detail is fresh.
• Describe what you saw and heard, not what you think it meant. "Threw a cup across the lounge" is a record. "Kicked off" isn't.
• Include the setting: the time, the place, who was there, the noise level and anything that had changed that day.
• Note when it didn't happen in a situation where you'd expect it. NICE asks for the events and situations that predict when behaviour will and won't occur.
• Make sure someone reads them. Bring them to the monthly review, look for patterns, and tell staff what changed because of what they wrote.

There's a fair challenge here too. The National Autistic Taskforce, in a discussion paper published by Skills for Care, argues that too much focus on counting behaviour and ABC analysis can draw attention away from the person's own experience and distress. The chart is a tool for understanding the person. It isn't the point. For layouts and worked examples, see our guide to ABC charts for behaviour.

Steps or stages? What the frameworks actually say

Search for PBS and you'll find "three stages", "five steps" and even "eight steps". We couldn't find a single official step list in the main UK sources. Here's what they do set out.

Three themes and ten elements. The PBS Competence Framework (2015) uses the UK definition by Gore and colleagues (2013), which has ten elements in three groups. A refined UK definition was published in 2022; it builds on the 2013 one rather than replacing it. The framework sets the elements out like this:

The framework stresses that these elements aren't a menu. A service that does a functional assessment but ignores the person's quality of life isn't doing PBS. Nor is a service with a lovely values statement and no data.

Five outcomes of a functional assessment. The framework says the process starts with a functional assessment, and lists what it should produce: a clear description of the behaviour; the events, times and situations that predict when it will and won't happen; the consequences that keep it going (what it does for the person); a summary statement linking these together; and direct observation that supports that summary. NICE NG11 (recommendation 1.5.9) lists the same five things. That's one sourced answer to "five steps".

Three kinds of strategy in the plan. NICE NG11 (recommendation 1.6.1) groups the plan's strategies three ways: proactive, preventive (at the first signs of distress) and reactive. That's one sourced answer to "three stages", and it matches the green, amber and red of a colour-coded plan.

A phased assessment. NICE (recommendations 1.5.1 and 1.5.11) describes a phased approach: start with an initial assessment, and move to a more in-depth one if the support isn't working or the reason for the behaviour isn't clear.

We couldn't trace an "eight steps of PBS" list to the Competence Framework, NICE, Skills for Care or CQC. If a course teaches one, it's fair to ask where it comes from.

What the evidence says

PBS rests on decades of research in behaviour analysis. The 2015 competence framework points to systematic reviews of more than 250 single-case studies showing that behavioural interventions can produce good outcomes. It also points to a UK randomised trial (2009) in which people supported by a specialist PBS team did better than those given usual care.

The evidence isn't all one way, and it's fair to say so. A larger NIHR-funded trial in 23 community learning disability services in England (246 adults, published 2018) found that training staff in PBS, as delivered in that study, didn't reduce challenging behaviour over 12 months compared with usual care. That fits what the guidance stresses: PBS depends on good assessment, a plan staff actually follow, and data that someone reads. The trial suggests a training course on its own isn't enough.

PBS and ABA

PBS grew out of applied behaviour analysis (ABA). The Competence Framework says many of its assessment and support methods are grounded in behaviour analysis, and the Challenging Behaviour Foundation says the approach uses processes of applied behaviour analysis. But the UK definition of PBS is wider than behaviour analysis alone. It puts quality of life and human rights at the centre, rejects aversive and punitive interventions, involves the person and their family in designing the support, and uses other evidence-based approaches alongside behavioural ones, such as speech and language therapy or therapy for trauma.

That link matters, because ABA has faced substantial criticism from the autistic community. The National Autistic Taskforce paper says some autistic people and families support PBS, but a significant proportion have concerns that it isn't aligned with autistic people's priorities, partly because of those roots in ABA. If you support autistic people, it's worth knowing that this debate exists and listening to how the person and their family feel about it.

Criticisms of PBS

One detailed UK critique is the National Autistic Taskforce's discussion paper Recognising Behaviour as Distress in Practice (January 2024), written from an autistic perspective and published by Skills for Care. Skills for Care supports it as a discussion paper but says it doesn't necessarily represent its position. The paper argues that:

• care should focus on autonomy, reducing stress and distress, and a meaningful life, rather than on managing behaviour and risk;
• PBS has become too dominant in adult social care, and other approaches, such as low arousal approaches and intensive interaction, deserve more attention;
• the evidence for PBS is mixed. It cites the 2018 NIHR trial above, while noting that the trial was itself criticised for not looking at day-to-day practice in the services.

It also reports that the 2022 UK "State of the Nation" report on PBS raised concerns about PBS being used indiscriminately.

None of this means PBS is wrong. Its stated values (quality of life, rights, less restriction, involving the person) are close to the rights-based, quality-of-life approach the Taskforce paper itself argues for. The arguments are about whether a framework built around behaviour is the right starting point for everyone, and about PBS being used indiscriminately. For a manager, the practical test is the same either way: is this person's life getting better, and are we listening to them?

PBS and reducing restrictive practice

Reducing restrictive practice is part of PBS, not an extra. A restrictive practice is anything that limits a person's movement, freedom or independence. That includes physical restraint, locked doors, removing belongings and medicines used to control behaviour.

• The law: Regulation 13 says care must not include acts intended to control or restrain a person unless they are necessary to prevent a risk of harm and a proportionate response to it.
• National guidance: Positive and proactive care (Department of Health, 2014) asks services to make restrictive interventions a last resort. It describes PBS as a framework that can improve quality of life and reduce behaviours that challenge, and so reduce the use of restrictive interventions. It expects individualised support plans, including behaviour support plans, for everyone known to be at risk of restrictive interventions.
• Capacity: if a service user lacks capacity to consent to a restriction, the decision must be made in their best interests, and before you act, the Mental Capacity Act 2005 requires you to consider whether the same aim can be met in a way that is less restrictive of their rights and freedom.
• Training: any training that includes restrictive practices should meet the Restraint Reduction Network (RRN) Training Standards.
• Recording: every restriction is written down with its reason, the person's view, its lawful basis and a plan to reduce it.

If a person who lacks capacity to consent to their care arrangements may be deprived of their liberty in a care home, the Deprivation of Liberty Safeguards (DoLS) still apply. In June 2026 the Supreme Court changed the test for when care amounts to a deprivation of liberty ([2026] UKSC 16), the Liberty Protection Safeguards are not in force, and official guidance is being updated. Follow your local authority's and DHSC's current guidance, and take advice on individual cases.

Our guide to restrictive practice and restraint reduction covers the types of restriction and how to record them.

PBS and STOMP

STOMP stands for stopping over medication of people with a learning disability and autistic people. It's a national NHS England programme. NHS England says people should only be given psychotropic medication for the right reasons, in the lowest dose, for the shortest time, with regular reviews, and that STOMP is the responsibility of everyone involved, including social care.

PBS and STOMP depend on each other. NICE NG11 (recommendation 1.8.2) says antipsychotic medicine should be considered for behaviour that challenges only when certain conditions apply. Those are: psychological or other support hasn't worked within an agreed time, treating a health problem hasn't helped, or the risk is very severe. NG11 adds that it should only ever be offered alongside psychological or other interventions. In a PBS plan, any "when required" (PRN) medicine for distress usually sits as the last reactive (red) strategy, with its own PRN protocol agreed with the prescriber. In its recommendations on antipsychotic medicine (1.8.4), NG11 says PRN medication should be prescribed for as short a time as possible, with its use recorded and reviewed. It also says the medication should be reviewed if the person's environment changes, for example significant staff changes or a move to a new care setting. See our guides to PRN protocols and LeDeR, STOMP and annual health checks.

PBS and Right support, right care, right culture

Right support, right care, right culture is CQC's statutory guidance for services supporting autistic people and people with a learning disability. It has three parts:

• Right support: the model of care and setting maximise choice, control and independence.
• Right care: care is person-centred and promotes dignity, privacy and human rights.
• Right culture: the "ethos, values, attitudes and behaviours of leaders and care staff ensure people using services lead confident, inclusive and empowered lives".

The guidance expects that a service's approach to behaviour is not reactive or reliant on restrictive practices or seclusion. It also expects the service to show how the PBS values base informs its practice. In other words, CQC wants to see PBS in how the home is run, not only in a plan in a folder.

Do care homes have to use PBS? We're not aware of any law in England that requires every care home to use PBS by name. But Regulation 13 forbids control or restraint that isn't necessary to prevent, or proportionate to, a risk of harm, and NICE NG11 recommends a behaviour support plan based on the function of the behaviour for people with a learning disability whose behaviour challenges. For services supporting autistic people and people with a learning disability, CQC's statutory guidance expects the service to show how PBS values inform its practice.

Who's who in UK PBS standards and training

• The PBS Academy publishes the PBS Competence Framework and standards for services, training and individual practitioners.
• BILD (the British Institute of Learning Disabilities) runs PBS workforce development programmes and PBS qualifications at levels 4 and 5 through its Centre for the Advancement of PBS. Its certification arm, BildACT, is licensed by the Restraint Reduction Network to certify training against the RRN Training Standards.
• The Restraint Reduction Network publishes the Training Standards, a set of ethical standards for any training that includes restrictive practices.
• Skills for Care hosted and funded the workshops that wrote the PBS Competence Framework. It runs a peer review of PBS training providers against the PBS Academy training standards, and links to a "First Step to Foundation" PBS competence framework.

The Competence Framework has three areas: creating high-quality care and support environments; functional, contextual and skills-based assessment; and developing and putting in place a behaviour support plan, then checking it works. It describes three levels: direct contact (care and support workers), behaviour specialist, supervisory or managerial, and higher-level specialist or organisational. Most care staff need the direct contact level. Team leaders and managers need enough of the second level to supervise the plan, check it's being followed and read the data.

A quick check of your own service

• Ask a bank or agency worker about one service user: what are their early signs, and what do you do at amber?
• Read last month's ABC charts for one person. Did anything in the plan change because of them?
• Check each plan's last review date, and whether anything has changed since: new staff, a new routine, new medicines.
• List every restriction in place and the date it was last reviewed.
• Check who each service user's key worker is, and what happens to the pairing when that person is on leave or moves on.

How Kiwi handles this

Kiwi (our product) has a PBS section in the care plan, one of its 24 standard sections. A separate challenging behaviour plan has sections for green, amber, red and blue (after an incident) strategies, and a place to record the restrictions in place and the dates they were last reviewed. Like the other care plan sections, each can have its own next review date (shown as overdue when it passes), and when it's changed the earlier version is kept. A member of staff can sign it to confirm they've read it and will follow it; Kiwi shows who signed last and when, and flags it for re-signing if it's been updated since. ABC charts, incidents, body maps and daily logs are recorded in Kiwi too, so the plan and the records behind it are in one system.

There's more on how Kiwi is set up for learning disability services on our learning disability care software page.

If you'd like to see how Kiwi's care plan sections, PBS section and ABC charts work, book a demo.

Frequently asked

What is positive behaviour support?

Positive behaviour support (PBS) is a way of supporting people with a learning disability, and autistic people, whose behaviour challenges. Staff work out why the behaviour happens, then change the person's support and surroundings so they have a better life and need the behaviour less. It combines person-centred values with behavioural science, and it rejects punishment and aversive approaches.

What is a PBS plan?

A PBS plan, or behaviour support plan, is the written plan for one person, based on an assessment of why their behaviour happens. NICE guideline NG11 says it should set out proactive strategies that improve the person's quality of life, a new skill to teach, ways to calm them at the first signs of distress and reactive strategies for behaviour that can't be prevented. It should also name who is responsible and be reviewed often.

Who can write a PBS plan?

We're not aware of any law in England that says who must write a PBS plan. NICE NG11 says it should be based on a shared understanding of why the behaviour happens and should name a person who coordinates it. The PBS Competence Framework says the person's key carers, and the person themselves whenever possible, should be fully involved. For severe or complex behaviour, NICE recommends a multidisciplinary assessment with specialist input, for example through the community learning disability team.

Is positive behaviour support the same as ABA?

No, though they're related. PBS draws on applied behaviour analysis (ABA) to understand why behaviour happens. But PBS is a wider framework built on person-centred values and human rights. Its goal is a better quality of life, not just changing behaviour, it rejects aversive and punitive approaches, and it uses other evidence-based approaches too. Some autistic people and families still have concerns about PBS because of its roots in ABA, which has faced substantial criticism from the autistic community.

What are the stages of positive behaviour support?

There's no single official list of stages or steps. The UK definition used in the PBS Competence Framework has ten elements in three themes: values, theory and evidence base, and process. The process starts with a functional assessment of why the behaviour happens, then a plan with proactive, preventive (early signs) and reactive strategies, then monitoring and review over the long term. NICE NG11 groups a plan's strategies the same three ways.

How often should a PBS plan be reviewed?

NICE NG11 recommends reviewing a behaviour support plan frequently: fortnightly for the first two months and monthly after that, particularly if the behaviour or the use of restrictive interventions increases, or the person's quality of life falls. Treat it as a live document between reviews too. The PBS Competence Framework says a repeat assessment should always follow any change in how the person's behaviour presents.

Does positive behaviour support work?

The evidence is mixed but encouraging. Systematic reviews of more than 250 single-case studies found that behavioural interventions can produce good outcomes, and a 2009 UK trial found people supported by a specialist PBS team did better than those given usual care. But a larger NIHR-funded trial published in 2018 found that training staff in PBS, as delivered in that study, didn't reduce challenging behaviour over 12 months. Good assessment, a plan staff follow and data someone reads all matter.

Is PBS only for people with a learning disability or autism?

PBS was developed in learning disability services, and the UK definition and standards focus on people with a learning disability, including autistic people with a learning disability, of all ages. Its core ideas of understanding why behaviour happens, improving quality of life and reducing restriction are used more widely. The 2022 UK definition notes that the approach may need to look different for people living with dementia or with serious mental health needs, so check which guidance applies to the person you support.

Sources

• PBS Coalition / PBS Academy: Positive Behavioural Support, a competence framework (March 2015) (also linked from the PBS Academy)
• PBS Academy: home page and "What is PBS?"
• PBS Academy: Standards for services
• BILD, PBS Academy, Challenging Behaviour Foundation, HEE and Skills for Care: The key messages about Positive Behaviour Support (April 2017)
• Skills for Care: Positive behavioural support (PBS)
• National Autistic Taskforce: Recognising Behaviour as Distress in Practice, a discussion paper (January 2024, published by Skills for Care)
• Challenging Behaviour Foundation: PBS, your questions
• BILD: Centre for the Advancement of Positive Behaviour Support and about the CAPBS model of PBS
• Restraint Reduction Network: Training Standards
• NICE NG11: Challenging behaviour and learning disabilities (recommendations 1.5.1, 1.5.8 to 1.5.11, 1.6.1, 1.8.2, 1.8.4 and 1.9)
• CQC: Services for autistic people and people with a learning disability (Right support, right care, right culture)
• CQC: Right support, right care, right culture: how providers can demonstrate they meet the requirements
• CQC: Regulation 13, safeguarding service users from abuse and improper treatment
• legislation.gov.uk: Regulation 13 of the 2014 Regulations
• legislation.gov.uk: Mental Capacity Act 2005, section 1 (the principles)
• GOV.UK: Positive and proactive care, reducing the need for restrictive interventions (2014)
• NHS England: STOMP and STAMP
• NIHR Journals Library: Hassiotis et al., staff training in PBS, cluster randomised trial (HTA vol 22, issue 15, 2018)
• GOV.UK: Mental Capacity Act Code of Practice

Sources last checked: 27 October 2026.