Assessing the Impact of Psychotropic Medication Changes on Challenging Behavior of Individuals with Intellectual Disabilities

A review of the use of psychotropic medication to address challenging behaviour in neurodevelopmental disorders

Engagement in challenging behaviour (e.g., aggression, self-injury) is reported to occur in neurodevelopmental disorders such as intellectual disabilities (ID), autism spectrum disorder (ASD), and fragile X syndrome (FXS). Common interventions to address these behaviours include both behavioural and pharmacological approaches. Although psychotropic medications are commonly used to address challenging behaviour in ID, ASD, and FXS, demonstration of the effectiveness of treatment is limited. Furthermore, research examining interaction effects between psychotropic medication, challenging behaviour, and environmental events within specific neurodevelopmental disorders such as ID, ASD, and FXS is scarce. The purpose of this chapter is to provide an overview of challenging behaviour within ID, ASD, and FXS and of the effectiveness of psychotropic medication as an intervention for challenging behaviour within these neurodevelopmental disorders. Finally, research examining how psychotropic medication may impact the relationship between challenging behaviour and environmental events is reviewed.

Management of psychotropic medications in adults with intellectual disability: a scoping review

BACKGROUND/OBJECTIVE(S)

Psychotropic medications are commonly prescribed among adults with intellectual disability, often in the absence of a psychiatric diagnosis. The aim of this scoping review is to provide an overview of the extent, range, and nature of the available research on medication use and practices and medication management in people with intellectual disability taking psychotropic medications for behaviours that challenge.

MATERIALS AND METHODS

A scoping review of research studies (qualitative, quantitative, and mixed design) and Grey Literature (English) was carried out. Databases included: Ovid MEDLINE, Embase, CINAHL, JBI Evidence Synthesis, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, and Scopus. A three-step search strategy was followed, with results screened by two independent reviewers. Data was extracted independently by two reviewers using a data extraction tool with results mapped and presented using a narrative form supported by tables and diagrams to the research questions.

RESULTS

Following the removal of duplicates, records were screened, full texts assessed, and 49 studies were included. Medication outcomes included reduced repetitive, stereotypic, and/or aggressive behaviours. High dosing/prescribing in the setting of an absent/unclear clinical indication was associated with worsening of symptoms for which psychotropics were prescribed. While psychotropics had a role in managing behaviours that challenge, reducing or discontinuing psychotropics is sometimes warranted. Study designs were frequently pragmatic resulting in small sample sizes and heterogeneous cohorts receiving different doses and combinations of medications. Access to multidisciplinary teams, guidelines, medication reviews, staff training, and enhanced roles for carers in decision-making were warranted to optimize psychotropic use.

CONCLUSIONS

These findings can inform prescribing interventions and highlight the need for timely and comprehensive patient outcome data, especially on long-term use of high doses of psychotropics and what happens when reduce or stop prescribing these doses.KEY MESSAGESPsychotropic medications are frequently prescribed for people with intellectual disabilities, often at high doses and these medications are associated with both positive and negative patient outcomes.Work to rationalize psychotropic use has been reported with interventions aiming to reduce polypharmacy or deprescribe a single psychotropic medicine. These interventions had mixed success and risk of relapse was documented in some studies.Limitations in sample size and heterogenous patient cohorts make it challenging to understand the risks and benefits associated with reducing or stopping psychotropic medicines.Patient, carer, and clinician partnerships are critical to advance medication management.

Descriptive Longitudinal Analysis of Stereotypy and Corresponding Changes in Psychotropic Medication

INTRODUCTION

Psychotropic medication is often prescribed to individuals with intellectual and developmental disabilities who engage in challenging and other behavior (e.g., aggression and stereotypy, respectively), but there is limited understanding of the effects of these medications on behavior.

OBJECTIVE

Within the context of a larger study that evaluated the effects of psychotropic medication regimen changes on the presentation of challenging behavior, this study describes the presentation of stereotypic behavior of three individuals diagnosed with autism spectrum disorder.

METHODS

Stereotypy was measured during weekly, one-hour, direct observations and during the control and ignore conditions of functional analyses of challenging behavior (which were conducted following changes in psychotropic medication regimens).

RESULTS

Patterns of stereotypy varied over time, but not significantly, and at times seemed to coincide with medication changes.

DISCUSSION

Our results suggest stereotypy persists throughout adulthood; however, additional research is needed.

Psychotropic Medication Monitoring in a Human Services Organization for Children with Autism Spectrum Disorder: Description and Evaluation of Interdisciplinary Team Review

Children with autism spectrum disorder (ASD) are often prescribed psychotropic medications but pharmacotherapy is typically conducted and evaluated based on clinical judgement without reference to objective measurement of treatment effectiveness and combined efficacy of pharmacological-behavioral interventions. We describe an interdisciplinary review team (IRT) model at a human services organization for children with ASD that was designed to standardize a process of psychotropic medication monitoring through (1) coordinated involvement of medical, nursing, behavior analyst, and special education professionals, (2) parent-guardian participation, (3) data-driven decision making, and (4) high-level administrative support. Our description includes case illustrations of medication reduction-elimination trials with five students and social validity assessment of IRT clinicians, nurses, and parent-guardians. Key components of the IRT model are emphasized with associated practice and research recommendations.

Long-term functional stability of problem behavior exposed to psychotropic medications

Psychopharmacological and behavioral interventions are often combined in the treatment of problem behavior in people with intellectual and developmental disability (IDD). However, little is known about the interaction between medication pharmacodynamics and behavior function. A better understanding of these mechanisms could serve as the conceptual foundation for combined interventions. The current analysis is a systematic replication of Valdovinos et al. (2009). We conducted continuous functional analyses within analogue reversal and parametric analyses monitoring the impact of various dosages of primarily antipsychotic medications on problem behavior and its function. Four individuals with IDD and problem behavior who were also receiving psychotropic medications participated. Medication adjustments produced small to negligible decreases in problem behavior, and behavior function remained largely unchanged through the 14 medication adjustments evaluated. The continuous functional analysis helped to identify what could be delayed medication effects on problem behavior. The clinical and methodological implications of this replication are discussed.

Changes in Stereotypical Behavior Following Chlorpromazine Termination: Polypharmcy Effects on Response Class Membership

OBJECTIVES

A paucity of information exists relating to the possible biological and environmental interactions influencing the occurrence of stereotypical behavior. In particular, there is limited research on the effects of psychotropic medication use on stereotypy presentation in individuals diagnosed with developmental disabilities such as intellectual disability and autism spectrum disorder.

METHODS

We studied the stereotypy of a man with autism spectrum disorder and intellectual disability across 2 years. The topographies of stereotypical behavior included walking in circles, head tapping, arm flinging, and object stereotypy. These behaviors were observed weekly while the participant received daily dosages of 25 mg of chlorpromazine, 1.5 mg of lorazepam, and 2,500 mg of divalproex. At Week 75, chlorpromazine was discontinued while the other drugs and dosages were maintained.

RESULTS

We observed a statistically significant decrease in walking in circles, but no changes in the other topographies of stereotypy.

CONCLUSIONS

The results suggest that the gross motor activity was differentially affected by the chlorpromazine discontinuation and also suggests that alterations in dopamine receptor binding may have selectively influenced changes in stereotypical responding.

Treatment algorithm for the use of psychopharmacological agents in individuals prenatally exposed to alcohol and/or with diagnosis of fetal alcohol spectrum disorder (FASD)

Psychotropic medication treatment of individuals who have experienced prenatal alcohol exposure (PAE) has lagged behind psychosocial interventions. Multiple psychotropic medications are often prescribed for those diagnosed with a range of neurodevelopmental disabilities and impairments of PAE (neurodevelopmental disorder associated with prenatal alcohol exposure and/or fetal alcohol spectrum disorder [ND-PAE/FASD]). Despite the diverse comorbid mental disorders, there are no specific guidelines for psychotropic medications for individuals with ND-PAE/FASD. When prescribed, concerned family members and caregivers of individuals with ND-PAE/FASD reported that polypharmacy, which was typical and adverse effects render the psychotropic medications ineffective. The objective of this work was to generate a treatment algorithm for the use of psychopharmacological agents specifically for individuals with ND-PAE/FASD. The development of decision tree for use to prescribe psychotropic medications incorporated findings from previous research and the collective clinical experience of a multidisciplinary and international panel of experts who work with individuals with ND-PAE/FASD, including an algorithm specialist. After multiple meetings and discussions, the experts reached consensus on how best to streamline prescribing along neurodevelopmental clusters. These were subdivided into four ligand-specific, receptor-acting medication targets (hyperarousal, emotional dysregulation, hyperactive/neurocognitive, and cognitive inflexibility). Each cluster is represented by a list of common symptoms. The experts recommended that prescribers first ensure adequate psychosocial and environmental, including sufficient dietary, exercise, and sleep support before prescribing psychotropic medications. Treatment then progresses through three steps of psychotropic medications for each cluster. To support established treatment goals, the most function impairing clusters are targeted first.

Evaluating the Relationship between the Rate and Temporal Distribution of Self-Injurious Behavior

Self-injurious behavior (SIB) presents unique challenges as researchers have identified that some SIB may be resistant to treatment. The unit of analysis in this research is often the frequency of behavior with relatively little attention devoted to the analysis of inter-response time relations. We assessed whether changes in the rate of SIB were also associated with changes in the temporal distribution of this behavior in the presence and absence of systematically manipulated environmental variables. This study included three participants diagnosed with profound intellectual disabilities who engaged in SIB maintained by both negative and automatic reinforcement. For two of the participants, we used a multiple baseline design across participants to assess the effects of noncontingent access to preferred activities on both the rate and temporal distribution of SIB. For the third participant, we used a reversal design to assess the effects of a change in daily schedule (i.e., attending or not attending work) on the rate and temporal distribution of SIB. For all three participants, antecedent manipulations decreased the rate of SIB; however, operant contingency values (a measure of temporal distribution) did not change in a corresponding fashion. These data suggest that although antecedent manipulations may decrease the overall rate of the behavior, once SIB is emitted, additional instances are likely to occur close together in time.

Characterizing Mood States in Individuals Diagnosed with Bipolar Disorder and Intellectual Disability

INTRODUCTION

The purpose of this study was to gain additional insight on patterns of behavior of three individuals dually diagnosed with Intellectual disability (ID) and Bipolar disorder as they cycled between elevated and depressed mood states.

METHODS

Data were collected from weekly, one hour observations across a period of several months. The total duration of time spent engaged in target responses (pacing, rocking, and talking), in addition to indirect measures of activity (irritability and hyperactivity subscale of the Aberrant Behavior Checklist-Community; ABC-C), were assessed to characterize and monitor changes in overall state.

RESULTS

While observable behavior seemed to be a good indicator of overall state, ABC-C irritability and hyperactivity subscales were not. Additional analyses included lag sequential analyses of environmental stimuli and conditions potentially correlated with observed behavior.

CONCLUSIONS

Our findings suggest that observable behavior may be one way to monitor the progression of Bipolar disorder in those with ID; however, further research needs to be conducted.

Adverse Side Effects of Psychotropic Medication and Challenging Behavior: Pilot Work Assessing Impact

Psychotropic medications are often prescribed to reduce challenging behavior in individuals with intellectual and developmental disabilities (IDD). Functional analyses (FAs) have demonstrated utility in assessing medication impact on behavior; however, the impact of adverse side effects (ASE) on challenging behavior is under-assessed. The purpose of this study was to develop a methodology, similar to FAs, to explore potential medication ASE impact on challenging behavior in seven individuals with IDD. Results revealed response rate differences in designed ASE conditions for most participants. Outcomes support further development and use of this methodology to assess the presence and impact of ASEs.