Integrating behavioral and pharmacological interventions in treating clients with psychiatric disorders and mental retardation

Temporary Increases in Problem Behavior and Sleep Disruption Following Decreases in Medication

Conditional rates of problem behavior for weeks that followed medication decreases and no medication changes were compared for 12 individuals who exhibited severe problem behavior (e.g., self-injury, aggression). The results indicate that conditional rates of problem behavior were higher following medication decreases than following no changes in medication. During the subsequent week, rates of problem behavior typically decreased without reinstating the prior dosage of medication. Additional analyses suggest that the first medication decrease typically produced the highest increase in problem behavior. Decreases in medication also disrupted sleep patterns for several individuals. Possible operant conceptualizations of behavior changes produced by medication decreases are discussed.

Irritability and Problem Behavior in Autism Spectrum Disorder: A Practice Pathway for Pediatric Primary Care

OBJECTIVE

Pediatric primary care providers (PCPs) caring for patients with autism spectrum disorder (ASD) often encounter irritability (vocal or motoric outbursts expressive of anger, frustration, or distress) and problem behavior (directed acts of aggression toward other people, self, or property). The Autism Intervention Research Network on Physical Health and Autism Speaks Autism Treatment Network charged a multidisciplinary workgroup with developing a practice pathway to assist PCPs in the evaluation and treatment of irritability and problem behavior (I/PB).

METHODS

The workgroup reviewed the literature on the evaluation and treatment of contributory factors for I/PB in ASD. The workgroup then achieved consensus on the content and sequence of each step in the pathway.

RESULTS

The practice pathway is designed to help the PCP generate individualized treatment plans based on contributing factors identified in each patient. These factors may include medical conditions, which the PCP is in a key position to address; functional communication challenges that can be addressed at school or at home; psychosocial stressors that may be ameliorated; inadvertent reinforcement of I/PB; and co-occurring psychiatric conditions that can be treated. The pathway provides guidance on psychotropic medication use, when indicated, within an individualized treatment plan. In addition to guidance on assessment, referral, and initial treatment, the pathway includes monitoring of treatment response and periodic reassessment.

CONCLUSIONS

The pediatric PCP caring for the patient with ASD is in a unique position to help generate an individualized treatment plan that targets factors contributing to I/PB and to implement this plan in collaboration with parents, schools, and other providers.

Treatment models for treating patients with combined mental illness and developmental disability

The presence of co-occurring psychiatric disorders among individuals with developmental disability (DD) requires clinicians to adjust and modify standard mental health assessment and treatment planning. In particular, assessment includes input from a multi-disciplinary team and as a result, diagnosis is frequently a synthesis of data from many different points of view. Treatment planning and implementation commonly include a collection of highly specialized, individualized programs that focus on the long term management of both disorders. Crises and recurrence of mental disorders are commonplace in part due to the presence of ongoing risk and vulnerability factors for mental disorders. As a result, the need for emergency interventions, specialized respite services, hospitalization and other transition services is extensive. The quality, availability and access to these services vary considerably. Many programs are concentrated in metropolitan or university-based centers and pose hardships based on geographic distance. The availability and utilization of services is affected by political, economic, socio-cultural and psychological forces that impact both the willingness to use services and the distribution of professionals trained and qualified to manage individuals with dual diagnoses. The complex interaction between each of these factors determines the structure, function, and capacity for innovation built into current service models.

Integrative treatment in persons with intellectual disability and mental health problems

BACKGROUND

Clinical experience has proven thus far that a monodisciplinary treatment approach to behavioural and psychiatric problems in persons with intellectual disability (ID), such as psychotropic medication or behaviour modification programmes, has yielded limited success. It is clear that the complexity of behavioural and psychiatric problems in this population calls for a treatment approach from different perspectives.

METHODS

A multidimensional treatment approach to the persons with ID who suffer from behaviour problems and psychiatric disorders is described.

RESULTS

Four dimensions - biological, psychological, social and developmental - are represented as well in an integrative diagnosis as in an integrative treatment, embodied by cooperation of different professionals, such as a psychiatrist, psychologist, pedagogues, social worker, nurse and, where possible, the person's caretakers. The developmental dimension receives a salient attention of assessors. By introducing the developmental dimension in diagnostics and treatment, the bio-psycho-social dimensions are set in a new context, more appropriate for persons with ID.

CONCLUSION

The integrative treatment should not be primarily directed towards the symptoms of the disorder but towards restoring a person's mental well-being. The disorder is combated through treatment of the underlying processes that have led to its onset. Different treatment methods from different perspectives may be applied. Strategy and methodological procedures of an integrative treatment are discussed by way of case presentations.

Psychotropic medication in adults with mental retardation: prevalence, and prescription practices

People with mental retardation comprise an overmedicated population. Studies the last 20 years or so indicate that nearly 50% of people with mental retardation receiving care have been using psychotropic medication, in the treatment of psychiatric disorders and/or problem behaviours. The recent years guidelines for prescription of psychotropics have been developed, emphasizing, e.g. the presence of a diagnosis, consideration of alternatives, and evaluation. In spite of all this, we found that 37% of people with mental retardation in one Norwegian county were using psychotropics, mostly neuroleptics. Moreover, prescriptions frequently violated current guidelines, especially when conducted by general practitioners. For example, a lot of prescriptions had not been indicated by a diagnosis, alternatives to medications had rarely been explored, and evaluation of effects and side effects were exceptions. Psychiatrists complied more with current guidelines. Implications of the findings are discussed.

Psychiatric disorders in adolescents with developmental disabilities: longitudinal data on diagnostic disagreement in 150 clients

The current paper describes the prevalence of psychiatric diagnoses in a large sample (n = 150) of adolescents with developmental disabilities who were hospitalized for inpatient psychiatric treatment. Differential diagnoses made during their inpatient stay in a specialty unit for the assessment and treatment of dually diagnosed adolescents are presented and contrasted with longitudinal/historical data on these same patients' diagnoses prior to admission. Results indicate that these individuals received a wide spectrum of diagnoses during their adolescent years. The paper offers indirect support that correctly diagnosing psychiatric conditions is often challenging in adolescents with developmental disabilities. Factors related to diagnostic complexity and misdiagnoses (false positives and false negatives) are discussed. Longitudinal data on psychotropic medication usage for these individuals are also presented.

Mentoring treatment teams to integrate behavioral and psychopharmacological treatments in developmental disabilities

Individuals with developmental disabilities often have a concomitant psychiatric disorder severe enough to require treatment. The behavioral endpoint of psychiatric disorders may require integrated behavioral and psychopharmacological treatments to stabilize their condition and enhance their quality of life. We used a mindfulness-based mentoring model to facilitate the integration of behavioral and psychopharmacological treatments at the treatment team level. Using a multiple baseline design across treatment teams, we assessed the degree of integration of these two treatment modalities using a 23-item rating scale, and then introduced mentoring successively across the three treatment teams. Following mentoring, six follow-up assessments at monthly intervals were undertaken to assess functioning of the treatment teams in the absence of mentoring. The low levels of integration of behavioral and psychopharmacological treatments occurring during baseline improved significantly within each team commensurate with the mentoring. Further, the enhanced treatment team functioning was maintained during a 6-month follow-up period. Mentoring of treatment teams may be an effective first step in integrating behavioral and psychopharmacological treatments that are deemed essential in the care and treatment of individuals with developmental disabilities and mental illness.