, Volume 11, Issue 1, pp 99–111 | Cite as

Comparative Effectiveness of Caregiver Training in Mindfulness-Based Positive Behavior Support (MBPBS) and Positive Behavior Support (PBS) in a Randomized Controlled Trial

  • Nirbhay N. SinghEmail author
  • Giulio E. Lancioni
  • Oleg N. Medvedev
  • Rachel E. Myers
  • Jeffrey Chan
  • Carrie L. McPherson
  • Monica M. Jackman
  • Eunjin Kim


Caregivers of individuals with intellectual and developmental disabilities are often stressed due to the demands of the job, including the nature and severity of challenging behaviors of the clients, work conditions, degree of management support for the staff, and the demands of implementing some interventions under adverse conditions. Mindfulness-Based Positive Behavior Support (MBPBS) and PBS alone have been shown to be effective in assisting caregivers to better manage the challenging behaviors of clients with intellectual and developmental disabilities. The aim of the present study was to undertake a head-to-head assessment of the effectiveness of MBPBS and PBS alone in a 40-week randomized controlled trial. Of the 123 caregivers who met inclusion criteria, 60 were randomly assigned to MBPBS and 63 to PBS alone, with 59 completing the trial in the MBPBS condition and 57 in the PBS alone condition. Results showed both interventions to be effective, but the caregiver, client, and agency outcomes for MBPBS were uniformly superior to those of PBS alone condition. In addition, the MBPBS training was substantially more cost-effective than the PBS alone training. The present results add to the evidence base for the effectiveness of MBPBS and, if independently replicated, could provide an integrative health care approach in the field of intellectual and developmental disabilities.


Mindfulness-Based Positive Behavior Support MBPBS PBS Stress Compassion fatigue Burnout Secondary traumatic stress Perceived stress Cost-effectiveness 



A portion of the data included in this paper were first presented at the Second International Conference on Mindfulness (ICM-2), Sapienza University, Rome, Italy, May 11–15, 2016, and with additional data at the IASSIDD 4th Asia-Pacific Regional Congress: Inclusiveness and Sustainable Development, November 13–17, 2017, Bangkok, Thailand.


Preparation of this article was supported by a National 461 Research Foundation of Korea (NRF) grant (NRF-2010-361- 462 A00008) funded by the Korean Government (MEST).

Compliance with Ethical Standards

Conflict of Interest

NNS is the developer of the MBPBS program. The authors declare no conflict of interest and they do not work for, consult to, and own shares in or receive funding from any company or organization that would benefit from this article.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


  1. Adams, R. E., Boscarino, J. A., & Figley, C. R. (2006). Compassion fatigue and psychological distress among social workers: a validation study. American Journal of Orthopsychiatry, 76(1), 103–108.PubMedGoogle Scholar
  2. Allen, D., James, W., Evans, J., Hawkins, S., & Jenkins, R. (2005). Positive behavioural support: definition, current status and future directions. Tizard Learning Disability Review, 10, 4–11.Google Scholar
  3. Anderson, J. L., Albin, R. W., Mesaros, R. W., Dunlap, G., & Morelli-Robbins, M. (1993). Issues in providing training to achieve comprehensive behavioral support. In J. Reichle & D. P. Wacker (Eds.), Communicative alternatives to challenging behavior: integrating functional assessment and intervention strategies (pp. 363–406). Baltimore, MD: Paul H. Brookes.Google Scholar
  4. Anderson, J. L., Russo, A., Dunlap, G., & Albin, R. W. (1996). A team training model for building the capacity to provide positive behavioral supports in inclusive settings. In L. K. Koegel, R. L. Koegel, & G. Dunlap (Eds.), Positive behavioral support: including people with difficult behavior in the community (pp. 467–490). Baltimore, MD: Paul H. Brookes.Google Scholar
  5. Brooker, J. E., Julian, J., Webber, L., Chan, J., Shawyer, F., & Meadows, G. (2013). Evaluation of an occupational mindfulness program for staff employed in the disability sector in Australia. Mindfulness, 4, 122–136.Google Scholar
  6. Brooker, J. E., Webber, L., Julian, J., Shawyer, F., Graham, A. L., Chan, J., & Meadows, G. (2014). Mindfulness-based training shows promise in assisting staff to reduce their use of restrictive interventions in residential services. Mindfulness, 5, 598–603.Google Scholar
  7. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Earlbaum.Google Scholar
  8. Cohen, S., & Williamson, G. (1988). Psychological stress in a probability sample of the United States. In S. Spacapan & S. Oskamp (Eds.), The social psychology of health: Claremont Symposium on Applied Social Psychology (pp. 31–67). Newbury Park, CA: Sage.Google Scholar
  9. Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24, 385–396.Google Scholar
  10. Devereux, J. M., Hastings, R. P., & Noone, S. J. (2009a). Staff stress and burnout in intellectual disability services: work stress theory and its application. Journal of Applied Research in Intellectual Disabilities, 22(6), 561–573.Google Scholar
  11. Devereux, J. M., Hastings, R. P., Noone, S. J., Firth, A., & Totsika, V. (2009b). Social support and coping as mediators or moderators of the impact of work stressors on burnout in intellectual disability support staff. Research in Developmental Disabilities, 30(2), 367–377.PubMedGoogle Scholar
  12. Didden, R., Lindsay, W. R., Lang, R., Sigafoos, J., Deb, S., Wiersma, J., et al. (2016). Aggressive behavior. In N. N. Singh (Ed.), Handbook of evidence-based practices for individuals with intellectual and developmental disabilities (pp. 727–750). New York: Springer.Google Scholar
  13. Donnchadha, S. O. (2017). Stress in caregivers of individuals with intellectual or developmental disabilities: a systematic review of mindfulness-based interventions. Journal of Applied Research in Intellectual Disabilities. Scholar
  14. Dunlap, G., Heineman, M., Knoster, T., Fox, L., Anderson, J. L., & Albin, R. W. (2000). Essential elements of in-service training in positive behavior support. Journal of Positive Behavior Intervention, 2(1), 22–32.Google Scholar
  15. Epp, K. (2012). Burnout in critical care nurses: a literature review. Dynamics (Pembroke, Ont.), 23(4), 25–31.Google Scholar
  16. Harmell, A. L., Chattillion, E. A., Roepke, S. K., & Mausbach, B. T. (2011). A review of the psychobiology of dementia caregiving: a focus on resilience factors. Current Psychiatry Reports, 13(3), 219–224.PubMedPubMedCentralGoogle Scholar
  17. Hastings, R. P., & Horne, S. (2004). Positive perceptions held by support staff in community mental retardation services. American Journal of Mental Retardation, 109(1), 53–62.PubMedGoogle Scholar
  18. Hastings, R. P., Horne, S., & Mitchell, G. (2004). Burnout in direct care staff in intellectual disability services: a factor analytic study of the Maslach burnout inventory. Journal of Intellectual Disability Research, 48, 268–273.PubMedGoogle Scholar
  19. Hatton, C., Emerson, E., Rivers, M., Mason, H., Mason, L., Swarbrick, R., Kiernan, C., Reeves, D., & Alborz, A. (1999). Factors associated with staff stress and work satisfaction in services for people with intellectual disability. Journal of Intellectual Disability Research, 43(4), 253–267.PubMedGoogle Scholar
  20. Hieneman, M., & Fefer, S. A. (2017). Employing the principles of positive behavior support to enhance family education and intervention. Journal of Child and Family Studies, 26(10), 2655–2668.Google Scholar
  21. Kabat-Zinn, J. (1994). Wherever you go, there you are. New York, NY: Hyperion.Google Scholar
  22. Khorsan, R., Counter, I. D., Crawford, C., & Hsiao, A. F. (2011). Systematic review of integrative health care research: randomized control trials, clinical controlled trials, and meta-analysis. Evidence Based Complementary and Alternative Medicine, e-Cam ID: 636134, doi: Scholar
  23. Leoni, M., Corti, S., Cavagnola, R., Healy, O., & Noone, S. J. (2016). How acceptance and commitment therapy changed the perspective on support provision for staff working with intellectual disability. Advances in Mental Health and Intellectual Disabilities, 10(1), 59–73.Google Scholar
  24. Lin, J. D., Lee, T. N., Yen, C. F., Loh, C. H., Hsu, S. W., Wu, J. L., et al. (2009). Job strain and determinants in staff working in institutions for people with intellectual disabilities in Taiwan: a test of the job demand-control-support model. Research in Developmental Disabilities, 30(1), 146–157.PubMedGoogle Scholar
  25. Lucyshyn, J. M., Dunlap, G., & Freeman, R. (2015). A historical perspective on the evolution of positive behavior support as a science-based discipline. In F. Brown, J. L. Anderson, & R. L. De Pry (2015). Individual positive behavior supports: a standards-based guide to practices in school and community settings (pp. 3-25). Baltimore, MD: Paul H. Brookes.Google Scholar
  26. MacDonald, A. (2016). Staff training in positive behavior support. In N. N. Singh (Ed.), Handbook of evidence-based practices for individuals with intellectual and developmental disabilities (pp. 443–466). New York: Springer.Google Scholar
  27. Maslach, C., Schaufeli, W. B., & Leiter, M. P. (2001). Job burnout. Annual Review of Psychology, 52(1), 397–422.PubMedGoogle Scholar
  28. Medvedev, O. N., Krägeloh, C. U., Hill, E. M., Billington, R., Siegert, R. J., Webster, C. S., et al. (2017). Rasch analysis of the Perceived Stress Scale: transformation from an ordinal to a linear measure. Journal of Health Psychology. Scholar
  29. Melamed, S., Shirom, A., Toker, S., Berliner, S., & Shapira, I. (2006). Burnout and risk of cardiovascular disease: evidence, possible causal paths, and promising research directions. Psychological Bulletin, 132(3), 327–353.PubMedGoogle Scholar
  30. Morris, K. R., & Horner, R. H. (2016). Positive behavior support. In N. N. Singh (Ed.), Handbook of evidence-based practices for individuals with intellectual and developmental disabilities (pp. 415–441). New York: Springer.Google Scholar
  31. Noone, S. J., & Hastings, R. P. (2009). Building psychological resilience in support staff caring for people with intellectual disabilities: pilot evaluation of an acceptance-based intervention. Journal of Intellectual Disabilities, 13, 43–53.PubMedGoogle Scholar
  32. Noone, S. J., & Hastings, R. P. (2010). Using acceptance and mindfulness-based workshops with support staff caring for adults with intellectual disabilities. Mindfulness, 1, 67–73.Google Scholar
  33. Piko, B. (1999). Worker-related stress among nurses: a challenge for health care institutions. The Journal of the Royal Society for the Promotion of Health, 119(3), 156–162.PubMedGoogle Scholar
  34. Quenot, J. P., Rigaud, J. P., Prin, S., Barbar, S., Pavon, A., Hamet, M., & Moutel, G. (2012). Suffering among carers working in critical care can be reduced by an intensive communication strategy on end-of-life practice. Intensive Care Medicine, 38, 55–61.PubMedGoogle Scholar
  35. Rose, J., Jones, F., & Fletcher, B. (1998). Investigating the relationship between stress and worker behavior. Journal of Intellectual Disability Research, 42(2), 163–172.PubMedGoogle Scholar
  36. Schaufeli, W. B., & Buunk, B. P. (2003). Burnout: an overview of 25 years of research and theorizing. In M. J. Schabracq, J. A. M. Winnubst, & C. L. Cooper (Eds.), The handbook of work and health psychology (2nd ed., pp. 383–424). Chichester, UK: Wiley.Google Scholar
  37. Singh, N. N., Lancioni, G. E., Winton, A. S. W., Singh, A. N., Adkins, A. D., & Singh, J. (2009). Mindful staff can reduce the use of physical restraints when providing care to individuals with intellectual disabilities. Journal of Applied Research in Intellectual Disabilities, 22, 194–202.Google Scholar
  38. Singh, N. N., Lancioni, G. E., Winton, A. S. W., Karazsia, B. T., & Singh, J. (2013). Mindfulness training for teachers changes the behavior of their preschool students. Research in Human Development, 10(3), 211–233.Google Scholar
  39. Singh, N. N., Lancioni, G. E., Winton, A. S. W., Karazsia, B. T., Myers, R. E., Latham, L. L., & Singh, J. (2014). Mindfulness-Based Positive Behavior Support (MBPBS) for mothers of adolescents with autism spectrum disorder: effects on adolescents’ behavior and parental stress. Mindfulness, 5, 646–657.Google Scholar
  40. Singh, N. N., Lancioni, G. E., Karazsia, B. T., Myers, R. E., Winton, A. S. W., Latham, L. L., & Nugent, K. (2015). Effects of training staff in MBPBS on the use of physical restraints, staff stress and turnover, staff and peer injuries, and cost effectiveness in developmental disabilities. Mindfulness, 6, 926–937.Google Scholar
  41. Singh, N. N., Lancioni, G. E., Manikam, R., Latham, L. L., & Jackman, M. M. (2016a). Mindfulness-based positive behavior support in intellectual and developmental disabilities. In I. Ivtzan & T. Lomas (Eds.), Mindfulness in positive psychology: the science of meditation and wellbeing (pp. 212–226). East Sussex, UK: Taylor & Francis.Google Scholar
  42. Singh, N. N., Lancioni, G. E., Karazsia, B. T., & Myers, R. E. (2016b). Caregiver training in Mindfulness-Based Positive Behavior Supports (MBPBS): effects on caregivers and adults with intellectual and developmental disabilities. Frontiers in Psychology, 7, 98. CrossRefPubMedPubMedCentralGoogle Scholar
  43. Singh, N. N., Lancioni, G. E., Karazsia, B. T., Chan, J., & Winton, A. S. W. (2016c). Effectiveness of caregiver training in mindfulness-based positive behavior support (MBPBS) vs. training-as-usual (TAU): a randomized controlled trial. Frontiers in Psychology, 7, 1549. CrossRefPubMedPubMedCentralGoogle Scholar
  44. Skirrow, P., & Hatton, C. (2007). Burnout amongst direct care workers in services for adults with intellectual disabilities: a systematic review of research findings and initial normative data. Journal of Applied Research in Intellectual Disabilities, 20(2), 131–144.Google Scholar
  45. Stamm, B. H. (2010). The concise ProQOL manual (2nd ed.). Pocatello, ID: Scholar
  46. Van Gordon, W., Shonin, E., & Griffiths, M. D. (2015). Towards a second generation of mindfulness-based interventions. Australia and New Zealand Journal of Psychiatry, 49(7), 591–592.Google Scholar
  47. White, C., Holland, E., Marsland, D., & Oakes, P. (2003). The identification of environments and cultures that promote the abuse of people with intellectual disabilities: a review of the literature. Journal of Applied Research in Intellectual Disabilities, 16(1), 1–9.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Nirbhay N. Singh
    • 1
    Email author
  • Giulio E. Lancioni
    • 2
  • Oleg N. Medvedev
    • 3
  • Rachel E. Myers
    • 4
  • Jeffrey Chan
    • 5
  • Carrie L. McPherson
    • 6
  • Monica M. Jackman
    • 7
  • Eunjin Kim
    • 8
  1. 1.Department of Psychiatry and Health Behavior, Medical College of GeorgiaAugusta UniversityAugustaUSA
  2. 2.Department of Neuroscience and Sense OrgansUniversity of BariBariItaly
  3. 3.Centre for Medical and Health Sciences Education, School of MedicineUniversity of AucklandAucklandNew Zealand
  4. 4.WellStar School of NursingKennesaw State UniversityKennesawUSA
  5. 5.Movement for the Intellectually Disabled of SingaporeSingaporeSingapore
  6. 6.McPherson Therapy and ConsultingGreenvilleUSA
  7. 7.Little Lotus Therapy and ConsultingPort St. LucieUSA
  8. 8.Institute of Mind HumanitiesWonkwang UniversityIksanSouth Korea

Personalised recommendations