Association for Behavior Analysis International

Problem behavior can be treated with applied behavior analysis (ABA) or psychotropic medication, and each carries its own advantages and disadvantages. ABA is resource intensive, requires technically trained personnel, and the benefits may develop slowly but it has none of the side effects associated with psychotropic medications, their benefits are cumulative and often outlive the treatment period. Psychotropic medication’s effects appear quickly, their benefits can be striking, and are thought to be less expensive than ABA interventions. Finally, the educational and practicum training required for the two domains are nearly non-overlapping, so often only one approach is used or both are used with varying degrees of cooperation among practitioners, with impacts on families and clients. The two papers in this symposium examine treatment in this context. Chris Newland compares the costs of ABA with and without psychotropic medications and examines when ABA reduces the future use of psychotropic medication. Jennifer Zarcone discusses communicating with medical providers and families, and the ethical dilemmas presented when balancing their approaches with the therapeutic goals. The discussant, Maria Valdovinos, will examine these topics in the context of recent studies of joint treatment by psychotropic and behavioral interventions.

The target audience includes behavior analysts interested in psychopharmacology in applied settings, the use of psychotropic medications, and ethical and practical issues that arise when working with medical personnel. School staff and families will also benefit. Audience members should have a basic understanding of behavior analytic principles, how to read and interpret complex graphs, an appreciation of interdisciplinary service delivery, and at least an elementary understanding of psychotropic medications that are used.

We evaluated whether applied behavior analysis (ABA) services for children and youth in foster care reduces the future use of psychotropic medication and yields cost savings. Foster children 2 to 18 years old and their caregivers received ABA services to target specific problem behaviors and to train caregivers in behavior management. Most children were on psychotropic medication but those in the “Prevention Group” had no such history. An “ABA-Matched” group was matched on demographic variables and the severity of problem behavior. The costs of delivering services and medication was compared using these groups. A third group, called the “Medicaid-Matched” group was matched against the ABA-Matched group from a database of children receiving psychotropics through Medicaid. This last matching was based on demographics, medications prescribed on entering Medicaid, and the number of months receiving Medicaid-supported psychotropics. Costs for the older ABA-Matched children (> 12YO) were more than 10X the costs of age-matched prevention children, but costs for younger children (< 5YO) were similar. About half of the Prevention-Group children received no psychotropics in a three-year follow-up and the others received fewer than the ABA-Matched children. Thus, ABA services before commencing psychotropics prevented or greatly reduced the use of psychotropics over a three-year follow-up.

This presentation will focus on some of the ethical issues we face as behavior analysts when collaborating with families and medical providers to measure the effects of psychotropic medication. There are barriers to effective communication for many clinicians and some advice on how to negotiate those barriers will be discussed. In addition, a brief review of common measures (both indirect and based on direct observation) that can be used to assess the effects of medication on challenging behavior will be discussed. For example, we conducted an academic analog assessment with a 10-year-old with autism to assess the effect of an attention deficit disorder medication on off task and problem behavior on an impatient hospital unit. The figure shows that atomoxetine (Straterra) was highly effective in reducing problem and off task behavior. Additionally, we will discuss how we can help behavior analysts become more knowledgeable about behavioral pharmacology and medication effects during their graduate programs as well as via continuing education opportunities.