1. Mental health as motivational operation: Service-user and caregiver emotional states in the context of challenging behaviour Dr Nick Gore Tizard Centre, University of Kent Gore, N.J., & Baker, P. International Journal of Positive Behavioural Support (2017), 7 (1), 15-23

2. Introduction
A brief presentation of a relatively brief article – just published!
The context:
Special Edition of IJPBS Autumn 2013 – outline, describe and clarify PBS Framework
Increasing consideration of mental health variables in CB documentation and discourse overtime
Trauma or mental health based accounts sometimes presented as an alternative to models underpinning PBS or used to criticise the scope of the framework…………….

3. We would argue that PBS does explicitly recognise and support mental health variables in the context of challenging behaviour……………………………
Maintaining processes
Vulnerabilities
Impact
Pain reduction
Biological
Challenging Behaviour
Exclusion, Harm to self, Harm to others
Psycho-social
Other people’s behaviour
From Hastings et al. International Journal of PBS, December 2013

4. However, the finer detail of exactly how mental health variables may relate to behaviour that challenges have not been explored sufficiently
There is a danger therefore that even when recognised in PBS, assessment formulation and intervention for mental health needs are a kind of add on in practice……
In this paper we try to start the process of developing a more integrated understanding of some of the ways in which mental health variables might operate and best be understood in PBS
Just a start…..

5. 4-Term Contingency Diagrams
4 term contingency diagrams are integral to the conceptual model that informs PBS and assessment, formulation and intervention practices within the framework
3 term contingencies describe the relationship between a discriminative stimulus (antecedent), a given behaviour and a maintaining consequence.
4 term contingencies increase the complexity and power of explanation with inclusion of a further level of antecedent, the motivational operation

6. Whilst a discriminative stimulus effectively signals the availability of a reinforcing consequence contingent upon a given behaviour….
Motivational operations concern the value of that reinforcing consequence
2 Types of MO:
Establishing Operations (increase the value of a reinforcer and are associated with increases in behaviour)
Abolishing Operations (decrease the value of a reinforcer and are associated with reductions in behaviour

7. Service User Behaviour EO SD SR+
Deprivation from social attention
Caregiver arrives
Hits out
Attention provided
Hitting stops
Caregiver Behaviour EO
SR-
Toogood, S (2012) ‘Using contingency diagrams in the functional assessment of challenging behaviour’. International Journal of Positive Behavioural Support, 2(1), 3–10.

8. I will present just a few of the examples we provide……
In this article we use 4-term contingencies to provide illustrative examples of how mental health variables might relate to:
Service-user behaviour that challenges
Service user adaptive behaviour
Caregiver unhelpful behaviour in the context of service-user challenging behaviour
Caregiver helpful behaviour in general
Caregiver helpful behaviour in the context of service-user challenging behaviour
I will present just a few of the examples we provide……

9. Variability in Service User Challenging Behaviour
Consequence/caregiver behaviour
‘Stop that’ MO
Attention Deprivation
AND
Anxious State SD
Caregiver Arrives
Service User Behaviour
Hits Out
Function
Gain Attention
AND Momentary reduction in Anxiety
Increased rates /severity of hitting relative to attention deprivation alone
Here again we see an example of attention maintained behaviour, in which deprivation from attention increases the likelihood of any behaviour that will result in access to attention
But what if in addition the person was in a an anxous state? Here deprivation from attention might feel even more aversive and access to attention even more valued.
In such a situation we might predict increased rates or severity of challenging behaviour
The function of the behaviour might also be expanded to include some momentary reduction in anxiety for the individual
Note that this is really just one possible example – attention for some may actually be quite aversive when anxious – meaning escape maintained behaviour s become more likely
Social deprivation even more aversive and attention even more valued……
Of course for some people attention may be aversive when in anxious state and so escape from attention most likely – this is just an example…..
Accessing attention provides reassurance and helps to manage anxiety

10. Variability in Service User Adaptive and Challenging BehaviourMO
Stable Mood
Consequence/caregiver behaviour
‘let’s sit together’
Stable mood establishes attention as reinforcing
Service User Behaviour 1
Smiles
Function
Access Attention SD
Caregiver asks
‘how are you?
Consequence/caregiver behaviour
‘I’ll leave you alone’
Service User Behaviour 2
Hits Out
Low mood establishes avoidance of attention as reinforcing
This example considers variability in adaptive behaviour displayed by a service user.
In response to a caregiver saying ‘how are you’ we might observe the service user to sometimes smiles and sometimes hit out.
Different consequences are likely to follow – in the first case the service user ends up accessing attention and in the second avoiding this
How might this be explained?
Well one reason may relate to their emotional state functioning as an MO:
When in a stable mood for instance the service user may find attention to be very reinforcing
Whilst when in a low mood this might be quite aversive and something they would rather avoid MO
Low Mood
Function
Avoid Attention

11. Increases likelihood of behaviours that attain attention and decreasing likelihood of those that limit it
Increasing likelihood of behaviours that limit attention and decreasing likelihood of those that attain it
This diagram is a bit more complicated looking but describes the same thing
Here however there is a bit more detail about types of MO
You can see the possibility that as well as increasing the likelihood of behaviours that gain access to attention – a sable mood also serves as an abolishing operation for behaviours that result in withdrawal of attention
The opposite potentially being true for a low mood.

12. Consequence/caregiver behaviour Positive Interaction with Service User MO
Stable Mood
Caregiver Behaviour 1
‘How are you?’ SD
Service User
Arrives
Function
Attention
Caregiver Behaviour 2
Ignores Service User
Consequence/caregiver behaviour
Service User withdraws MO
Anxiety
The same things would really stand true when we consider the behaviour of caregivers.
In this case we might think of the presence of a service user as an SD for possible caregiver behaviour.
On some occasions we might see the caregiver responding positively ‘ asking ‘how are you’
On others less so ‘ perhaps ignoring the service user of withdrawing.
Different consequences are likely to follow – a positive interaction in the first case and a withdrawal from the services user in the second.
As with the previous example this variability could be attributable to different emotional states functioning as motivational operations. In this case a stable mood establishing social attention as reinforcing and anxiety establishing avoidance of this as reinforcing.
Function
Avoid Attention
Variability in Caregiver Helpful and Unhelpful Behaviour in General

13. Service User Challenging Behaviour
Variability in Caregiver Helpful and Unhelpful Behaviour in Response to Challenging Behaviour
Unhelpful caregiver behaviour that reduces CB in immediate term even more likely in context of caregiver anxiety anxiety…… MO
Service User Challenging Behaviour
AND
Anxiety
Consequence
Challenging behaviour reduces momentarily
AND anxiety reduces momentarily
Caregiver Behaviour 1
Reprimand
In the context of a stable mood more helpful caregiver behaviour may be possible even in presence of challenging behaviour…. MO
Service user challenging Behaviour
AND
Stable Mood
Consequence
Challenging behaviour reduces and positive interaction / long term gains
Finally we saw at the start that service user challenging behaviour is often experienced as aversive by caregivers which motivates behaviour that brings about a momentary reduction in such behaviour – even when this behaviour is unhelpful in the long term, aversive or restrictive.
We might posit that the likelihood of such behaviour would be increased even further dependent on caregiver’s emotional state – so when anxious we might expect to see caregivers making more reprimands in response to challenging behaviour (with some possible anxiety reduction also resulting from this in the short term)
But sometimes of course caregivers are able to act in more positive and helpful ways when presented with challenging behaviour. We might preit that this is more likely when they are experiencing a relatively stable mood.
The consequences of such behaviour are likely to be more beneficial in the long term
Ultimately we may expect more unhelpful caregiver responses to challenging behaviour in the presence of anxiety but when in s table mood positive responses could be possible – even thought challenging behaviour remains somewhat aversive.
Caregiver Behaviour 2
‘How can I help you?’

14. Discussion Multiple variants and additional relations are likely!
These are only some of the possible relationships
That consider only some aspects of mental health in the context of challenging behaviour
Multiple variants and additional relations are likely!
In the article we have also not provided a behavioural account of how the mental health variables arise or are maintained as the focus of analysis (rather the part they may play in maintenance of caregiver and service user challenging behaviour)
They do provide a start at integrating conceptual models for PBS in a way that could inform assessment and intervention practices in a way that is consistent with the values and theory of the framework more broadly

15. Thank You and Questions 