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| Medication Reduction: An Organizational Approach to Psychopharmacology in a Behavior Analytic Residential Treatment Program |
| Monday, May 25, 2020 |
| 8:00 AM–8:50 AM |
| Virtual |
| Area: BPN/DDA; Domain: Translational |
| Chair: Dawn O'Neill (Judge Rotenberg Educational Center; Contextual Behavioral Science Institute) |
| Discussant: R. Nicolle Nicolle Carr (The University of Oklahoma) |
| CE Instructor: Dawn O'Neill, Ph.D. |
| Abstract: An organizational approach to psychopharmacology in a behavior analytic residential treatment program is discussed. Our treatment teams and psychiatrist collaborate to reduce psychotropic medications, when clinically appropriate, for individuals with severe problem behavior. Our clients have typically attended previous residential treatment facilities, have been rejected from other placements, and are admitted to our program on a variety of psychotropic medications. We discuss changes in major problem behaviors following medication reduction and discontinuation. In many cases, we are able to successfully discontinue the use of psychotropic medications while concurrently implementing a comprehensive and intensive behavioral treatment program. Effective, program-wide behavioral interventions are reviewed. Several case studies highlight various level and trend changes observed when titrating psychotropic medications. Subsequently, a retrospective analysis examines the impact of clonidine withdrawal or discontinuation on the frequency of aggressive and self-injurious behavior. Aggressive and self-injurious behavior decelerates following clonidine discontinuation for the majority of the sample. Treatment providers should also be aware of temporary increases (i.e., agitation withdrawal) in problem behavior following medication reduction. Ethical considerations surrounding boundaries of competence, consultation, treatment efficacy, and least restrictive procedures are discussed. |
| Target Audience: behavior analysts, psychologists, behavioral scientists |
| Learning Objectives: 1. Understand an organizational approach to medication reduction. 2. Understand the possible impact of psychotropic medication changes on overt problem behavior, including agitation withdrawal. 3. Be familiar with ethical considerations surrounding multiple treatments and inter-disciplinary collaboration in reaching treatment decisions. |
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| Changes in Major Problem Behaviors following Psychotropic Medication Reduction |
| KAREN STUFFLEBEAM (Judge Rotenberg Educational Center), Dawn O'Neill (Judge Rotenberg Educational Center; Contextual Behavioral Science Institute), Nathan Blenkush (Judge Rotenberg Educational Center), Anthony Joseph (McLean Hospital; Harvard Medical School) |
| Abstract: An organizational approach to psychopharmacology within an intensive in-patient behavior analytic treatment facility is discussed. Medication changes are based on collaboration between psychiatry and clinical services. Several case studies are highlighted to demonstrate the impact of psychotropic medication reduction and discontinuation during intensive in-patient behavior analytic programming on aggressive, self-injurious, health dangerous, and major disruptive behavior. A variety of medications are titrated, including antipsychotics, mood stabilizers, and benzodiazepines. Generally, successful fading and discontinuation of psychotropic medications while concurrently implementing a comprehensive behavioral treatment program comprised of antecedent-based interventions, behavioral contracts and reminders, multiple schedules of reinforcement, differential reinforcement procedures, token systems and fines, and functional communication training is observed. Examples of various level and trend changes for major problem behaviors following psychotropic medication changes are explored. Examples of deceleration, temporary acceleration followed by deceleration (e.g., agitation withdrawal), and continued acceleration following medication changes are highlighted. The treatment utility of a clinical collaboration between psychiatry and behavior analysis is discussed. Ethical considerations for boundaries of competence, consultation, effective and least restrictive treatment are reviewed. |
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| Retrospective Analysis of Clonidine Efficacy for Aggressive and Self-Injurious Behavior |
| DAWN O'NEILL (Judge Rotenberg Educational Center; Contextual Behavioral Science Institute), Nathan Blenkush (Judge Rotenberg Educational Center), Anthony Joseph (McLean Hospital; Harvard Medical School) |
| Abstract: Clonidine, an autonomically active drug, is frequently prescribed in an effort to reduce different forms of aggressive and self-injurious behavior in people with various psychiatric diagnoses including attention deficit hyperactivity disorder, autism spectrum disorder, delirium, encephalopathy, mood disorders, and psychosis. Problematically, research cited to support the use of clonidine for aggressive behavior involves poor assessment methods (i.e., a line item for aggression on an indirect assessment). Furthermore, non-human animal research found that clonidine evokes aggressive and self-injurious behavior in mice. A retrospective analysis was conducted to examine the impact of clonidine withdrawal or discontinuation on the frequency of aggressive and self-injurious behavior for an intensive in-patient sample. Reduction of clonidine strongly correlated with clinically significant reductions of all forms of aggressive behavior in almost all patients. However, some patients temporarily engaged in an increase in aggressive behavior prior to maintaining lower levels of aggressive behavior. Clonidine discontinuation in patients with violent and self-injurious behavior may be an important approach to reducing such behavior, and treatment providers should be aware of the possibility of an initial increase in aggressive behavior while titrating medication. Effective, least restrictive, and multiple treatment ethical considerations are reviewed. |
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