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Strategies for Maximizing Psychotropic Drug Treatments for People with Autism and Other Developmental Disabilities: A Primer for Teachers and ParentsMarc Weeden, Ph.D, BCBA-DJuniper Gardens Childrens ProjectUniversity of KansasOverviewHistory/PrevalenceOff-Label PrescribingBehavior AnalysisIdentify Target Behavior (s)Record and Graph Relevant DataInterpret DataCommunicate Data to Appropriate Parties

History/PrevalencePsychotropic drugs medications prescribed with the intent of improving an individuals mood, cognition, or overt behavior1950s ThorazineApproximately 40-50% people with autism receive at least one psychotropic medication (e.g., Green et al., 2006; Goin-Kochel, Myers, & Mackintosh, 2007)Risperidone (Risperdal)A wide variety of psychotropic drugs are prescribed for people with autism and other developmental disabilities

Antipsychotics are the most prescribed (Poling et al., 2004)

Approved by the FDA in 2006 for treating irritability in people with autism between the ages of 5 and 17

Only drug that is FDA-approved as a psychotropic medication for people with autismOff-Label PrescribingAny other drug that is prescribed to improve the behavior of people with autism, the use is off-labelThe drug is prescribed for a purpose other than that for which it is specifically FDA-approvedAccepted medical practice if there is reasonable scientific evidence that a given drug is effective for a particular application

A Word of WarningDrugs do not selectively reduce problem behavior

Appropriate behavior may be reduced, too

Drugs may interact with other non-pharmacological interventions

Behavior AnalysisScientific study of behavior B.F. Skinner 1938Behavior is the subject of study Behavior can be observed, described, and recorded Data, Data, Data

Behavior is the subject of study (this includes thoughts, feelings, etc.)7Applied Behavior AnalysisDiscipline concerned with analyzing and modifying human behavior

Procedures based on basic principles of behavior are used by professionals and/or paraprofessionals to change behavior in socially significant ways (Miltenberger, 2004)

Emphasize teaching appropriate behavior in addition to decreasing problem behavior8Characteristics of ABABehavior is the subject of studyLabels are de-emphasizedBehaviors of interest are clearly definedVariables that control behavior are identified and modified Behavior change is measured over time Hypothetical underlying causes of behavior are avoided

ABA not used to change ADHD, for example,Used to change behavior exhibited by an individual diagnosed with ADHD

Labels are not causes of behavior, as they are not physical events. 9Applications of ABAOrganizational Behavior ManagementHealthSafetyDevelopmental DisabilitiesBehavioral PediatricsDrug AddictionRecyclingEducationBehavioral PharmacologySafety (Pilots, warehouse workers)10How to Identify Target Behavior (s)Behavioral Excess Behavior to be decreased in frequency, duration, or intensityExample: Smoking

Behavioral DeficitDesirable behavior to be increased in frequency, duration, or intensityExample: Exercising, Studying

Defining the Target Behavior (s)Definitions must be specific and related to actions

Example from Major League Baseball: Unsportsmanlike behavior

Cursing, throwing the bat, kicking the dirt

Defining the Target Behavior (s)Internal states (sad, angry, frustrated) are avoided

Internal states cant be observed or measured by others

Defining the Target Behavior (s)Labels (a bad sport) are not used because they do not describe an individuals actions

Definitions can vary from person to person

Precise definitions help to ensure data accuracy

Defining the Target Behavior (s)Labels are sometimes used to explain behaviorExample from Miltenberger (2004):A person is observed to repeat syllables or words when they speak (labeled a stutterer)To say the person repeats syllables or words because he/she is a stutterer is incorrect, as the label (stutterer) is not the cause of the behavior (repeating words or syllables when they speak)Same thing can be applied to individuals with autism

How to Record and Graph Relevant Data Record data at a time the behavior is likely to occurObservation sessions should be approximately the same length (e.g., all sessions are 20 min)Natural settings (e.g., classroom) are more likely to yield representative data than contrived settings (e.g., clinic)In contrived settings, however, outside sources of influence can be eliminated

How to Record and Graph Relevant DataDimension of behavior some quantifiable aspect of a behavior of interestFrequency number of times a behavior occurs in the observational periodDuration how long a behavior takes to occur from beginning to endHow to Record and Graph Relevant Data Baseline record the behavior prior to implementing the intervention

Allows for comparison and gives a clearer picture as to the effectiveness of the medication (is the behavior already decreasing due to a teacher intervention before the meds are given?)

Not always possible, as in the case of self-injurious behavior

How to Interpret DataRisperidone interventionExample 1: Talk outs is the behavior of interestDefined: Speaking at an audible level while teacher is providing instruction to the entire classUse frequency as method of recordingData recorded during math class each by paraprofessional

How to Interpret DataYou can say that the intervention was successful if all other sources of variability can be ruled out (e.g., other intervention started at the same time)

Be aware of side-effects (e.g., sedation)

How to Interpret DataMethylphenidate (Ritalin)Example 2: On-Task is the behavior of interestDefined: Participating in an assigned task (e.g., completing math problems)20 minute observation periodDurationRecording with a stop watch how long child is on-task

How to Communicate ResultsMake the graph easy to understand Meet as often as possible with the circle of support (e.g, parents, teachers, paraprofessionals)Let the data guide treatment decisionsThe MD will be able to better adjust or discontinue medication usage with accurate dataRisperidone Side EffectsDry MouthIncreased Appetite Weight GainSedationConstipationBlood Pressure ChangesDizzynessHeadacheTremors

Risperidone Side EffectsMake a plan to evaluate side effects

For example, closely monitor the weight of the person taking the drug (e.g., once per week)

Are they asking for more to drink and is this causing problems?

Might be difficult for an individual with autism to report adverse effectsSummaryDefine target behavior preciselySelect an appropriate system of measurementCommunicate resultsMake a plan to evaluate side effectsLet the data guide treatment decisionsConcluding CommentPsychotropic drugs are neither good nor badMedications can be helpful, harmful, or inconsequentialGood psychopharmacology, like any good intervention, is individualized and data basedThe task will rarely be easy, but it will always be worthwhileContact infomweeden@ku.eduChart14038475053453947524645

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