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| Real World Effects of Psychopharmacological Intervention Discontinuation on Destructive Behavior Frequency Amidst Comprehensive Behavioral Treatment |
| Saturday, May 25, 2024 |
| 10:00 AM–11:50 AM |
| Convention Center, 100 Level, 102 AB |
| Area: BPN/DDA; Domain: Applied Research |
| Chair: Anahita Masoum (Judge Rotenberg Center) |
| Discussant: Rajvinder Singh (McMaster University) |
| CE Instructor: Nathan Blenkush, Ph.D. |
| Abstract: Psychopharmacological interventions are widely prescribed to address severe self-injurious and aggressive behaviors. One tacit assumption regarding ongoing psychopharmacological treatment for patients with severe behaviors is that such interventions are reducing or have reduced the frequency and/or intensity of the problem behaviors. Such assumptions are supported, in many cases, by randomized controlled trials for specific indications and decades of use. However, there are reasons to doubt psychopharmacological intervention efficacy for severe destructive behaviors. First, the dependent variables utilized to assess drug efficacy are often non-specific and do not directly assess problem behaviors frequency or intensity. Second, people with severe problem behaviors are often exposed to polypharmacy obscuring individual drug effects. Third, people with severe behaviors often have fragmented treatment records complicating assessment. Finally, patients with severe behaviors often receive continuous psychopharmacological intervention. On the other hand, systematic tapering and discontinuation of all medications rarely occurs. Here, we summarize real-world effects of psychopharmacological medication tapering on problem behavior frequency of over 750 patients with severe problem behaviors across 24 years. Our data suggest that in a comprehensive behavioral treatment program, approximately 70% of individuals demonstrated a decreasing trend in aggressive and self-injurious behaviors during and after psychotropic medication tapering. |
| Instruction Level: Intermediate |
| Keyword(s): Aggression, Psychopharmacology, Self-injury, Severe behavior |
| Target Audience: Basic understanding of between group and single subject research designs. |
| Learning Objectives: At the conclusion of the presentation, participants will be able to: 1) Critically analyze dependent variable used in psychopharmacological studies. 2) State the real world findings (e.g. percent of patients who tolerated medication withdrawal without increases in problem behaviors) within the described population. 3) Describe various effects of medication on problem behavior frequency across patients. |
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23 Years of Taping Medications: The Effect on Self-Injurious and Aggressive Behavior Frequency |
| JOHN O'NEILL (Judge Rotenberg Educational Center) |
| Abstract: Psychotropic medications are assumed to generally reduce the frequency and/or intensity of severe aggression and self-injury. The Judge Rotenberg Center employs an approach to psychopharmacological treatment where psychotropic medications are gradually tapered (often eliminated) in the context of comprehensive behavioral treatment. We believe this approach is atypical and most patients with severe behaviors receive continuous psychopharmacological intervention. Medication increases (dose and number) and cross tapering are commonplace. Systematic tapering and discontinuation of all medications is rare. Anecdotally as an organization, we have observed rates of problem behaviors often decelerate amidst and after the discontinuation of psychotropic medications. However, the effect has never been assessed through large scale analysis. Here, we present data spanning 24 years summarizing the general effects of medication tapering on over 750 patients with severe aggression and self-injury. We summarize basic demographic information associated with the patients and describe behavior frequency and trend before, during, and after psychotropic drug discontinuation. The results suggest that in 70% of cases, the frequency of aggressive and self-injurious behaviors decreased during and after psychotropic medication tapering. |
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| Why Doubt Psychopharmacological Drug Efficacy? |
| NATHAN BLENKUSH (Judge Rotenberg Educational Center) |
| Abstract: Behavior analysts are often part of multidisciplinary teams that treat patients with severe problem behaviors. Patients with severe problem behaviors are often treated concurrently with behavioral interventions and psychotropic medications. However, there are reasons to doubt the efficacy of psychotropic medications. A cursory review of literature often shows research characterized by randomized controlled trials, significant p-values, and graphs showing differences between drug and placebo groups. However, lost in the study is dependent variable. While behavior analysts often rely of problem behavior frequency, drug studies rely on subjective rating scales such as the Aberrant Behavior Checklist – Irritability Subscale (developmental disabilities), Clinical Global Impression – Improvement Scale (mental illness), Alzheimer’s Disease Assessment Scale – Cognitive (Alzheimer’s disease), and many other similar measures. The items associated with these scales are often diverse and possibly lead conclusions that overstate the effect of the drug on problem behavior frequency or other behavioral effects. Here, these dependent variables and research methodologies are contrasted with common behavior analytic methodologies. |
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The Research Underlying Clonidine Efficacy for Aggression and Self-Injury Contrasted With Real World Efficacy |
| DAWN O'NEILL (Judge Rotenberg Center; Contextual Behavioral Science Institute) |
| Abstract: Clonidine is frequently prescribed to reduce aggressive and self-injurious behavior in people with various mental disorders. An anecdotal observation by a psychiatrist noting clonidine discontinuation often led to improvements in self-injury, aggression, and other destructive behaviors inspired a literature review and retrospective analysis of clonidine tapering. The basic literature review revealed that high doses of clonidine were historically used to evoke self-injury and aggression in basic studies with mammals. Studies showing clonidine efficacy for problem behaviors utilized subjective dependent variables with diverse and numerous line items. Finally, a retrospective analysis of clonidine discontinuation was conducted using frequency of aggressive and self-injurious behavior frequency as a dependent variable. A molar analysis with 89 participants showed that across three time points (e.g. clonidine, clonidine taper, and post clonidine), the mean rates of problem behavior decreased as the drug was discontinued. A repeated measures statistical analysis will be presented. Individual celeration charts showed individual differences with clonidine discontinuation resulting in low rates with some exceptions. In addition, some patients showed temporary increases in problem behaviors following clonidine reductions. |
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| Illustrating the Efficacy of Psychopharmacological Agents Using Problem Behavior Frequency and Standard Charts |
| NICHOLAS LOWTHER (Judge Rotenberg Educational Center) |
| Abstract: Thompson, Hackenberg, and Schaal (1989) summarized the efficacy of various antipsychotic agents used between 1971 and 1989 to treat destructive behaviors in people with developmental disabilities. They noted therapeutic effects had been observed but suggested “….in most cases [the therapeutic effect] was either (1) not observed, (2) observed, but at the expense of adverse side effects, (3) observed , but perhaps not to a clinically-relevant degree, (4) observed, but inferior to behavioral treatments….” Selecting from hundreds of case examples, here we show individual examples of various drug effects across 24 years of psychopharmacological treatment. In most cases, psychopharmacological treatments were discontinued without clinically significant increases in problem behaviors. However, in some cases, drug interventions were extremely effective or increased rates of problem behaviors. Taken together, the individual charts show detailed molecular analysis of how behavioral procedures can usually be substituted for psychopharmacological treatments without major increases in problem behaviors. The results are discussed in context of collaboration with multi-disciplinary teams. |
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