Positive Behaviour Support: Managing Behaviours That Challenge in Care Settings

When someone's behaviour puts themselves or others at risk, or closes the door to ordinary community life, the instinct in many care settings has historically been to manage the behaviour itself — through rules, restrictions, or physical intervention. Positive Behaviour Support (PBS) starts from a different question: what is this behaviour communicating, and what needs to change in the person's environment and support so it no longer needs to happen? That shift, from suppressing behaviour to understanding it, is now the expected standard across UK and Irish health and social care.

PBS is not a niche specialism reserved for behaviour analysts. It is increasingly core knowledge for any care worker supporting people with a learning disability, autism, dementia, or mental health needs, and it sits alongside related mandatory training such as Oliver McGowan Mandatory Training on Learning Disability and Autism. Providers building CPD pathways for staff who support people whose behaviour can challenge should look at Learnsignal's wider CPD training courses for structured, evidenced options.

What "Behaviours That Challenge" Actually Means

The term "behaviours that challenge" (sometimes still written as "challenging behaviour") describes behaviour of such intensity, frequency, or duration that it puts the physical safety of the person or others at serious risk, or significantly limits their access to ordinary community life. Crucially, national guidance is explicit that this is a description of a situation, not a label for a person. The Challenging Behaviour Foundation frames it around the principle that all behaviour happens for a reason — it is often communication rooted in an unmet need, whether physical, emotional, sensory, or environmental, particularly where a person has limited ways to express distress or pain verbally.

NICE guideline NG11 on challenging behaviour and learning disabilities reinforces this: behaviour that challenges often develops gradually and is shaped by personal factors (such as a severe learning disability, autism, or communication difficulties) alongside environmental triggers, including overly restrictive settings, low engagement, and inconsistent staffing. Recognising these patterns early, rather than only reacting once behaviour has escalated, is central to good practice.

What Positive Behaviour Support Is

The PBS Academy — a UK collective of organisations and individuals working in this field — describes PBS as a multi-component framework for understanding behaviour that challenges by assessing the broader social, physical, and individual context around it, then using that understanding to build evidence-based, person-centred support. The Challenging Behaviour Foundation similarly describes PBS as a person-centred approach that aims to improve someone's overall quality of life, not simply to eliminate an unwanted action.

In practice, this means PBS support plans typically combine:

• Understanding function — working out what the behaviour achieves for the person (escape from an unwanted situation, sensory need, attention, communication of pain or distress) through observation and, where needed, specialist functional assessment.
• Proactive strategies — changing the environment, routines, or communication support so the underlying need can be met before behaviour escalates, and helping the person build alternative skills to achieve the same purpose.
• Active support and quality of life — increasing meaningful activity, choice, and community access, since PBS Academy and CQC-linked quality-of-life work both recognise that a fuller, more engaged life reduces the likelihood of behaviours that challenge occurring in the first place.
• Reactive strategies as a genuine last resort — a clear, proportionate, least-restrictive plan for the rare moments when behaviour does escalate, used alongside proactive work rather than instead of it.

Moving Away From Purely Reactive and Restrictive Approaches

Older models of "managing" behaviour relied heavily on rules, sanctions, and physical intervention once behaviour had already become a safety risk. NICE NG11 sets out a phased, graded approach instead: initial assessment, then specialist multidisciplinary functional assessment where needed, with behaviour support plans built primarily around prevention and skills, and reactive strategies used only as a last-resort, carefully graded response that is documented and regularly reviewed. This is echoed in approaches to trauma-informed care, which recognises that some behaviours that challenge are rooted in past trauma, so a reactive, purely control-focused response can retraumatise the person rather than help them.

BILD (British Institute of Learning Disabilities) takes the same position through its work on reducing restrictive practice: restrictive interventions "can and do cause harm," and people experiencing distress are often the most vulnerable to their overuse, which is why services are expected to build therapeutic, rights-upholding approaches around six core strategies for restraint reduction, delivered through trauma-informed and relational methods, across learning disability, autism, mental health, education, and social care settings.

The Least Restrictive Option, and Why CQC Scrutinises It

Where a restrictive intervention (including physical restraint, restriction of movement, or chemical methods) is genuinely unavoidable, the established principle — reflected across BILD, Restraint Reduction Network, and CQC guidance — is that only the least restrictive option that manages the immediate risk should be used, for the shortest possible time, with the decision recorded, reviewed, and reduced over time.

This principle sits directly behind CQC's fundamental standards. Regulation 13 (safeguarding service users from abuse and improper treatment) requires a zero-tolerance approach to unnecessary or disproportionate restraint and deprivation of liberty: restraint is only permitted where it is necessary to prevent harm and proportionate to the risk, staff must be trained to a suitable level so control and restrictive practices are used only when absolutely necessary and in line with current national guidance, and providers must regularly monitor and review their use of restraint. Regulation 9 (person-centred care) requires providers to assess each person's needs and preferences collaboratively and support them to make or participate in decisions about their own care to the maximum extent possible — work that sits upstream of most PBS plans and reduces reliance on restriction. Regulation 12 (safe care and treatment) requires risks to service users to be properly assessed and mitigated, which includes ensuring that behaviour support and any restrictive elements of a care plan are based on a proper assessment rather than habit or convenience. Inspectors look for evidence that restrictive practice is the exception, individually justified, and actively being reduced — not a routine feature of how a service is run.

Who Typically Needs PBS Training

PBS knowledge is most directly relevant to care staff, healthcare assistants, nurses, and care managers supporting people with a learning disability, autism, dementia, or mental health needs — groups more likely to display behaviours that challenge as a result of unmet needs, communication barriers, or environmental mismatch. It is closely linked to other statutory and best-practice training, including mental capacity and safeguarding training, since decisions about restrictive support often intersect with capacity assessments; see Learnsignal's guidance on the Mental Capacity Act and DoLS training requirements for how those obligations interact with behaviour support planning. Managers responsible for governance and inspection readiness should also be familiar with how restrictive practice oversight fits into wider CQC compliance expectations.

Frequently Asked Questions

Is Positive Behaviour Support the same as restraint reduction training?

They overlap but are not identical. PBS is the broader, proactive framework for understanding and reducing the likelihood of behaviours that challenge occurring at all, built around function, environment, and quality of life. Restraint (or restrictive practice) reduction training, of the kind promoted by BILD and the Restraint Reduction Network, focuses specifically on minimising the use, duration, and severity of restrictive interventions when they are genuinely needed. A well-run PBS approach should reduce how often restrictive practice is needed in the first place.

Does "behaviours that challenge" mean the person is being difficult on purpose?

No. National guidance is consistent that this term describes behaviour, and the situation around it, not the person. Most guidance frames such behaviour as a form of communication or a response to an unmet need, distress, pain, or an environment that is not meeting the person's needs, rather than deliberate defiance.

When is restrictive practice acceptable in a care setting?

Only when it is necessary to prevent harm, proportionate to the level of risk, the least restrictive option available, used for the shortest time possible, and properly documented and reviewed. This is the standard reflected in CQC Regulation 13 and in BILD/Restraint Reduction Network guidance, and it should always sit alongside proactive PBS strategies rather than replace them.

What should a good PBS plan include?

Typically: an assessment of what the behaviour achieves for the person (its function); proactive changes to environment, routine, or communication support; skills-based alternatives that meet the same need; a clear, least-restrictive reactive strategy for emergencies only; and a plan for regularly reviewing and reducing any restrictive elements over time, in line with NICE NG11.

PBS asks care teams to look past the behaviour itself and understand what a person is trying to communicate through it — then to build support around that understanding rather than around control. For care providers, that shift is not just good practice; it is what CQC inspectors, NICE guidance, and organisations like BILD and the PBS Academy now expect as the baseline for supporting people whose behaviour can challenge.