Challenging Behavior of Persons with Mental Health Disorders and Severe Developmental Disabilities
Wiesler and Hanson
1999 American Association on Mental Retardation
Depressive symptoms – a dysphoric or irritable mood and/or a markedly diminished interest or pleasure in most or almost all activities.
May be associated with a combination of the following:
•1. significant weight loss or gain
•2. insomnia or hypersomnia
•3. psychomotor agitation or retardation
•4. fatigue or loss of energy
•5. feelings of worthlessness or excessive guilt
•6. diminished ability to become or remain involved in an activity requiring concentrations
•7. recurrent thoughts of death
Depressive Episode: a cluster of emotional and somatic signs and symptoms comprises a depressive episode. A major depressive episode is diagnosed when the individual experiences at least 5 of the above symptoms with one of the primary features and these symptoms represent change from previous functioning – during two consecutive weeks. These symptoms are out of proportion in intensity and duration to particular stressors and thus interfere with the individuals overall functioning.
Depressive Disorder: the diagnosis of major depressive disorder is made whenever the criteria for one or more major depressive episodes are met in the absence of any of the following that could account for the symptoms or represent other mental disorders:
- 1. mood disorder due to a general medical condition
- 2. substance induced mood disorder
- 3. dysthymic disorder
- 4. schizoaffective disorder
- 5. mood features associated with schizophrenia
- 6. bereavement
- 7. previous manic or hypomanic episode
Dysthymic Disorder: this is a chronic condition characterized by a sad, depressed mood most of the day, more days than not, for at least two years ( irritable mood for a minimum 1 year duration for children and adolescents. The depressed mood is followed by at least two of the following: problems involving appetite, sleep patterns, energy level, concentration,, low self-esteem and feelings of helplessness.
Given the presence of a negative mood state, distinguishing factors are particular predisposing situation and the resulting type, range, intensity and duration of symptoms.
Behavioral Equivalents of Depressive Symptoms
Because the presence of severe to profound mental retardation often makes it difficult to detect these classic criteria, symptoms of depression are detected through close attention to various behavioral equivalents, which are changes from previous level of functioning or status and are not a result of other current biomedical or psychosocial influences.
Depressed Mood, Irritability, Agitation:
Rarely or never smiles
Tearful for no apparent reason
Easily annoyed, provoked or angered
Increased difficulty in tolerating usual aggravations or disruptions in routine
Easily provoked to disruptive outbursts
If verbal, may repeatedly express desire to return to former residential setting
Decreased Interest or Pleasure
Usual activities are refused
Typical events serving as reinforcers lose their effectiveness
Spends excessive time alone
Minimal response to environmental stimuli
Minimal eye contact
Rarely initiates activity or interactions
Toileting and grooming skills may deteriorate
In severe cases of loss of interest and withdrawal, may soil self, become incontinent, and lose interest in grooming such as bathing and changing clothes
Lowered performances in programs such as work activities
Increased difficulty in maintaining attention to tasks, even routines
Appears confused in attempts to complete routines requiring concentration, focus and span of attention
Hypersomnia: sleep becomes a preferred activity
Gets upset when attempts are made to awake and direct into usual activities
Takes excessive naps during the day
Insomnia: reduction in number of hours spent in sleep during the night
Difficulty falling asleep
Repeatedly awakes in middle of night
Awakes one or more hours before time to get up and then remains awake for the rest of the day
May present new or more severe behavior problems at bedtime, during the night or early hours
Weight / Appetite
Increase: significant weight gain (5% of body weight over 1 month)
If free access is not available, may begin or increase frequency of food stealing and/or pica
Decrease: significant weight loss (5% body weight over 1 month)
Decreased food intake
Rejects favorite foods
Resists prompts to attend or complete meals
Psychomotor Retardation/Low Energy
Remains in one location with minimal motor activity for lengthy periods of time
Rarely initiates activity or interactions
Spends excessive time lying or sitting
May actively resist activities
May present catatonic signs
Extremely slow body movements
Feelings of Worthlessness
In person with verbal skills, uses self-derogatory remarks – “I’m retarded”, “I’m ugly”
Excessive Concern for Death and Self-Harm
In person with verbal skills, excessive expression of concern over death of family or friends, funerals, or dying
In more severely impaired, suicidal ideation may take the form of increased fearfulness, clinging dependency, mimicry of a suicidal act, or drawings suggestive of death and burial
Threats or attempts to harm self
Nonspecific Behavioral Symptoms
Occurrence/increased occurrence and severity or occurrence in new settings of various behavior problems such as aggression, self-injury, and tantrums out of proportion to social or environmental changes or events
Repeated complaints of aches, pains or physical ailments
A distinct period of abnormally and persistently elevated, expansive or irritable mood.
Inflated self-esteem or grandiosity
Decreased need for sleep
Flights of ideas or subjective experience that thoughts are racing
Increased goal-directed activity (may be social, work, school or sexual)
Excessive involvement in pleasurable activities that have a likelihood of painful consequences
A period of persistent and abnormally elevated, expansive or irritable mood lasting a minimum of 1 week (less if hospitalization is required)
This abnormal mood occurs in the presence of at least three of the above symptoms of mania (4 symptoms if the mood is only irritable)
The mood disturbance must be sufficiently severe to produce marked impairment in the person’s functioning
A period as above that lasts for at least 4 days.
Must be different from the person’s usual demeanor, be clearly a change in functioning, and not due to the direct physiological effects of a substance or general medical condition
When symptom patterns for both a manic episode and a major depressive episode are present for at least one week
Experiences of rapidly alternating moods of sadness, irritability and euphoria along with the symptom patterns of both conditions
Bipolar I; Bipolar II; Rapid Cycling Bipolar Disorder; Cyclothymic Disorder – see DSM_IV for detail
Behavioral Equivalents of Mania
Presence of symptoms reflect changes from previous level of functioning or status and are not a result of other current biomedical or psychosocial influences
Appears boisterous, excited; easily provoked to disruptive outbursts; periods of acute and excessive anger
Has unrealistic notions of own skills
Views self as peer to staff or bosses
Decrease in total sleep time
Behavior problems occur at night when prompted to go to and remain in bed
Flights of ideas
Jumps from one topic to another in a frantic manner
Increased rate of verbalization/babbling
Nonstop vocalizations/does not seem to be able to stop
Unable to stay on task when other activities occur
Unable to stop an activity
Excessive involvement in pleasurable activities
Masturbates excessively or at inappropriate times/locations
Persistently requests reinforcers
Loss of skills
May become incontinent of urine and feces during day or night
Decrease in daily living skills
Nonspecific Behavioral Symptom
Occurrence or increased occurrence, severity or occurrence in new settings of various behavior problems such as aggression, self-injury, and tantrums that are out of proportion to social or environmental changes or events
Repeated complaints of aches, pains, or physical ailments
Diagnostic Protocol for Detection of Mood Disorders
Individual clinical contact may reveal some impressions
Interviews with others who have knowledge of the person’s affect, social and problem behavior responsiveness through daily contact
Should be supplemented by direct observation of the person being assessed in selected residential, work, and related settings and conditions
Graphic display of behavioral data may be helpful
Structured interviews with informants, rating scales, and checklists of potential value in identification of mood disorder symptoms:
Aberrant Behavior Checklist
Children’s Depression Inventory
Emotional Disorders Rating Scale for Developmental Disabilities
Diagnostic Assessment for the Severely Handicapped
Psycopathology Instrument for Mentally Retarded Adults
Reiss Scale for Maladaptive Behavior
Integrative Psychosocial Model of Depression in People with Severe Mental Retardation : this model views the occurrence of depression as a product of both environmental events and personal vulnerability features.
Immediate Disruptive Effects
The process begins with stressors or life events that serve as onset instigators. For people with severe impairments, these stressors may represent a wide range of events or changes may be somewhat idiosyncratic and personal. Seemingly minor losses may have considerable meaning to a person who may also lack alternative skills in accommodating the losses.
The antecedent life events are of significance to the extent that they disrupt substantial important and relatively automatic behavior patterns. Predictable and expected valued daily patterned behaviors are no longer possible.
Reduction of Positive Reinforcers
This creates a loss of meaningful reinforcers and reduction in positive affective experiences. Interactions with the environment become balanced in a negative direction. Often these people have a limited number of alternative behavior patterns that consistently provide predictable and valuable positive consequences.
The disruption of patterned behaviors and the loss of valued reinforcers result in an immediate negative emotional reaction, the intensity and the pervasiveness of which is related to the importance of the loss to the person, the availability of the alternative sources of valued reinforcement and the person’s skill in obtaining these.
The aversiveness of the unpleasant event and the number of major stressors represent the best predictor of depressive onset. For people with severe impairments, limiting coping skills, a relatively impoverished motivational structure and a limited number of valued personal relationships, a hospitalization, separation from a friend or roommate, removal from a familiar environment with a structured familiar routine may represent huge stressors, especially if they are concurrent.
Following limited or unsuccessful attempts to gain replacements for the losses or to reduce the stressors, the person begins to focus excessively on the current state of emotional distress produced by the change. This excessive self-focus on the internal distress interferes with alternative attempts to gain environmentally based experiences that will replace the loss of the reinforcers. This results in intensification of the distressing dysphoric affective reactions; increasing withdrawal from social and program participation; a downward cycle is perpetuated. The limited cognitive and associated internal speech of severely impaired people become unduly influenced by the internal state of distress.
Appearance of Multiple Depressive Symptoms
The self-focus and dysphoria reduce the person’s social competency and render the person less attractive to others, further perpetuating the social isolation and dysphoria. A state of irritability or exaggerated need for emotional support evolves. Excessively dysphoric or irritable mood correlates with regression in basic self-care and bodily functions.
Personal characteristic may serve as a significant vulnerability influence. Personal histories that include experiences with rejection, restricted opportunities, segregation, inadequate social supports, victimizations, and infantilization are not uncommon in this population. Such personal features as learned helplessness, limited behavioral repertoires, limited skills of coping with negative emotional stress and an aberrant motivational structure may reflect the effects of the damaging histories. Additionally, current socioenvironmental factors such as a lack of or inconsistent social supports and limited access to a range of reinforcing events and associated emotionally enhancing experiences are vulnerability influences. All of this can contribute to intense emotional consequences when individuals lack the means of gaining valuable alternatives.
Learned helplessness: a helpless and inactive state produced whenever a person is unable to escape from or avoid punishing conditions. The experiences of many individuals with severe impairments especially of those with lengthy placement in institutional settings, are consistent with the development of a general characteristic of learned helplessness.
Social and Coping Skill Deficits
Limitations in the range and complexity of interpersonal and pother socially related skills such as those involving leisure and work as well as the skills of effectively coping with unfamiliar and emotionally laden incidents are inherent in the definition of severe and profound mental retardation. Limited social skills, excessive attachment and dependency on a small number of significant others, activities and objects, and limited leisure and work skills that restrict opportunities for obtaining significant sources of positive feedback all serve as significant psychosocial vulnerabilities.
Limited Range of Affective Attachments
Affective attachments are, in general, limited and with the continued loss of these attachments, people are a high risk for depressive responding upon loss of the objects of attachments. The person has limited replacement alternatives and thus, is without sources of valued social support. Observations suggest that some people with developmental disabilities may become emotionally blunted after a series of losses involving valued peers or caregivers and excessively cautious in developing further attachments.
Emotional lability and generalized irritability
Emotional lability related either to a pathological psychological history or to neurological and neurochemical abnormalities may represent a further vulnerability for development of depression. Without skills to cope and calm, the person would be increasingly likely to be influenced in daily activities by the internal distress produced by losses.
Additional motivational limitations
The life experiences of the people with severe and profound cognitive impairments frequently result in a highly constricted motivational structure. Due to limited exposure, the person does not learn to value a variety of activities and objects. The person is prone to become very dependent upon a limited number of reinforcers and may appear to be insatiable relative to them. When these are lost or greatly restricted, the person becomes vulnerable to depressive responding due to the lack of responsiveness to alternative sources of reinforcement.
Implications for treatment
Treatment for depression from a psychosocial perspective entails two major objectives. Therapeutic efforts initially address the current depressive symptoms with the objective of reducing or eliminating these as a means of returning the person to the level of functioning present prior to the current episode. The second objective involves the therapeutic efforts to reduce the psychosocial vulnerabilities that place the person at continued risk for future development of oppressive symptoms. Drug treatment may alleviate depressive symptoms but does not change the underlying pathophysiology or psychological or environmental vulnerabilities responsible for the disorder. As psychosocial therapies are designed to teach new coping strategies and to change other critical personal and socioenvironmental vulnerability features, they offer unique opportunities for increasing a person’s immunities that should mitigate the impact of the future psychological losses or disappointments.
Treatment strategies for meeting the initial therapy objective of regaining the predepression functional status:
•1. Whenever possible, prepare the person for major change or loss when these can be anticipated. Develop substitute or alternative personal relationships and routines that will be available on occurrence of the loss or change. If such preparation is not possible, or if ineffective, intervene as early as possible in the depressogenic process. Identify the losses that the person has experienced, the resulting behavioral routines that became nonfunctional and the range and types of interpersonal and activity reinforcing experiences that are lost. Develop alternatives to these valued routines.
•2. Provide frequent and consistent emotional support during the grieving and adaptation period. Remove excess demands and minimize additional aversive experiences. Recall, however, that depressive behaviors attract positive social reinforcement (sympathy, assurance, physical presence) and may be strengthened if the focus of the depressive behaviors is prolonged. Minimize attention to dependency and helplessness.
•3. Concurrently, expose the person to people, activities, and environments that offer suitable replacements. Provide a variety of social stimulation offered by a number of favored caregivers and peers. Expose to social models who predominately demonstrate positive affective behaviors. Identify activities (eating out, dancing, bowling) and objects (pictures, jewelry, miniature cars) that are valuable to the person and make these available. Use the necessary verbal and physical assistance needed to insure that the person does not withdraw into unresponsiveness.
Following resolution of a depressive episode, the range of personal and socioenvironmental vulnerabilities present with any specific person would become the focus of longer term therapeutic endeavors. The specific approaches selected would be determined by the particular constellation of psychosocial risk factors present for that individual.
Affective Disorders and Disruptive Behavioral Symptoms
Noted an increase in:
Mood and irritability
Following a diagnosis of depression and successful pharmacological treatment, pica became a minimal problem.
A diagnostic case formulation model that accounts for the occurrence as well as the persistent recurrence of nonspecific behavioral symptoms should thus consider:
•1. The complete stimulus complex that precedes and serves to instigate these symptoms
•2. the persons biopsychosocial vulnerabilities or risk factors for engaging in these nonspecific symptoms when confronted with this instigating stimulus complex as well as,
•3. those proximate consequences that follow behavioral occurrences and may contribute to their functionality and strength
The instigating stimulus complex may include the arousing/activating features of various components of a mood disorder. In these instances, the objective of a comprehensive diagnostic assessment is to “see past” the mood disorder and to ascertain the specific role served by the features of this condition in contributing to the occurrence, severity, fluctuation, and chronic recurrence of the behavioral symptoms. In this manner, informed speculation can be made about the extent of the reduction in critical features of the nonspecific symptom to be expected following effective treatment of the mood disorder.
Multimodal Contextual Behavioral Analytic Model
A multimodal(bio-, psycho-, and socioenvironmental modalities of influences) contextual ( contexts of instigating, vulnerability, and maintaining conditions) behavior analytic model is offered as a representation of this broader diagnostic-treatment case formulation process. (Holistic assessment).
Mood disorder features as instigating conditions – preceding events that, when present, influence the occurrence of nonspecific behavioral symptoms. These instigating conditions may serve either:
•1. A sufficient role
•2. or a contributing role
in influencing occurrence of these symptoms.
The sufficient role may sometimes represent the internal psychological condition such as a profoundly mentally retarded person without verbal skills communicating his needs by autoaggressive ear slapping associated with a dysphoric mood. The internal painful distress serves as a sufficient instigating stimulus condition for the auto aggression independent of any additional provocation from social or physical sources.
Whenever a persons nonspecific behavioral symptoms occur only in the presence of a critical level of discomfort produced by a dysphoric mood, a state dependent relationship is present. In this instance, effective treatment of the underlying stimulus condition (eg dysphoric mood) should remove or eliminate the instigating aversive internal state and the associated behavioral symptoms.
In other cases, a person’s behavioral symptoms, such as aggression or self-injury, may also be instigated by antecedent stimulus conditions unrelated to features of the person’s depression. In this instance, as the behavioral symptoms may appear in the absence of the mood disorder, a state-dependent relationship would not be present; interventions addressing both sets of instigating conditions would be necessary.
Contributing instigating events reflecting mood disorders.
In individuals with mental retardation diagnosed with rapid cycling disorder, occurrence of the behavioral symptoms was dependent on the psychological state associated with the psychiatric disorder plus occurrence of various staff prompts, even though different external prompts served as the instigating events during the different phases ( depression or mania) of the disorder. During the depressive episodes, the staff prompts intended to get the person involved in an activity, produced the problem behavior. During manic episodes, prompts to slow the person down or focus attention produced the behavioral symptom.
Those prompts, even though necessary conditions, were not sufficient in the absence of the mood state to instigate the nonspecific behavior. Both the staff prompts and the mood state formed the stimulus complex that represented the necessary precursors for the nonspecific behavior symptoms. Neither was sufficient, independent of the other, to produce the behavioral symptoms.
In this state dependent role, interventions resulting in removal of either of the contributing and necessary components of the stimulus complex (mood states or the prompt) would effectively manage the occurrence of the nonspecific behavior problem. The obvious focus of intervention, nonetheless, would be that of eliminating the aberrant mood states that rendered the staff prompts as aversive conditions to be removed or avoided through use of aggression or autoaggression. Following successful medication treatment of the bipolar disorder and removal of the associated instigating stimulus conditions (ie aberrant mood states), reduction or elimination of the nonspecific behavioral symptom would coincide with the concurrent reduction of the aversiveness of the staff reduction.
In state exacerbated relationship, the behavioral symptoms predate the mood disorder and increase in frequency and/or severity on occasion of the disorder. Instigating features of the mood disorder combine with other sources of provocation to increase the frequency and/or intensity of the behavioral symptoms but in isolation are neither necessary nor sufficient to produce these. In this instance, effective treatment of the mood disorder would result in reduction of the nonspecific behavioral symptoms related to the instigating features of the disorder.
Mood disorder features serve various roles as instigating conditions for nonspecific behavioral symptoms. On some occasions, various aberrant stimulus components resulting from the disorder may serve as contributing instigating conditions. These conditions may occasionally serve as necessary conditions for the occurrence of the behavioral symptoms.
Treatment of a person’s mood disorder may indeed be effective in reducing or eliminating the primary symptoms of the disorder but be ineffective in reducing the person’s nonspecific behavioral symptoms unless features of these mood disorders do contribute to the stimulus complex producing these behaviors.
Some personal; features associated with mod disorder may put a person at risk for engaging in nonspecific behavioral symptoms due to stress:
•1. The fluctuating intensity of mood states
•2. the mood lability
•3. increased likelihood of physical fatigue associated with sleep disturbances
•4. energy loss associated with eating difficulties
•5. and the aberrant activity levels
These states may either produce nonspecific behavioral symptoms or may increased the likelihood of these behaviors when the person is exposed to other sources of provocation. Add to that the deficits of coping skills, and an increase is likely in the occurrence of nonspecific symptoms.
Mood Influences on Functionality of Nonspecific Symptoms
Occurrence of nonspecific behavioral symptoms may result in changes in the internal affective states associated with a mood disorder. These changes may contribute to the strength and functionality of the behavioral symptoms. For instance, responding aggressively may remove a staff directive to attend a scheduled training program rendered aversive by a dysphoric mood state. As a result, aggressive responding is strengthened. Self-injurious face slapping may become functional as it results in frequent personal attention in a person who becomes excessively emotionally needy during periods of sadness. In these instances, the nonspecific behavioral symptoms become more likely under similar instigating conditions as these result in consequences valuable to the person.
Facts and Fiction About Behavior and MR/DD
Myth: Behavior always has functional significance and is under the control of the affected individual.
Premise: Behavior is an adaptive response to an external or internal stimulus.
Reality: Some behavior is involuntary and nonadaptive (eg, tics, and vocalizations of Tourette’s disorder)
Treatment implications: involuntary behavior may not respond to psychological interventions.
Myth: If a behavior has functional significance, it is unlikely to be related to a psychiatric disorder.
Premise: Determining the “meaning of the behavior” means that it can be explained in behavioral terms.
Reality: Behavior may represent an adaptive response to stress associated with a psychiatric disorder. (The onset of the illness may reproduce state-dependent behavior or result in an increase in state exacerbated behavior.
Treatment Implications: State-dependent and state-exacerbated behavior should be managed with treatment directed toward the underlying psychiatric disorder.
Myth: A person with severe or profound disabilities is too impaired to develop classic psychiatric disorders.
Premise: Because impairments in communication and functional skills preclude obtaining information about psychiatric symptoms (eg, suicidal ideation), people with severe impairments cannot manifest psychiatric disorders such as major depression.
Reality: DSM IV diagnostic criteria represent only approximations of syndromes, many of which have biochemical underpinnings. Criteria are based on the assumption that the diagnostically relevant behaviors and emotional experiences are highly associated.
Treatment implications: All patients, irrespective of the severity of their disabilities, who are treated with psychotropic drug therapy should have a DSM IV diagnostic formulation.
Myth: Bizarre behaviors, such as talking to yourself out loud, fantasy play or talking to an imaginary friend, represent manifestations of psychosis.
Premise: Bizarre behaviors indicate the presence of delusions or hallucinations.
Reality: Talking to yourself out loud, fantasy play and imaginary friends are best considered to be normal developmental behaviors that have persisted.
Treatment implications: These behaviors do not respond to antipsychotic drug therapy.
Myth: Drug therapy is a restrictive form of behavioral control. All regimens must, therefore, include a behavior plan and a timetable for discontinuing treatment.
Premise: Drug therapy directly affects behavior.
Reality: Behavior such as self-injury and aggression are too nonspecific to be considered as direct targets for drug therapy.
Treatment implications: The appropriate targets for drug therapy are the changes in neurophysiological function that mediate behavior associated with psychiatric disorders and central nervous system dysfunction.
The traditional view that all behavior is functionally defined is limiting. The traditional view was that people with MR/DD displayed maladaptive behavior because they lived in deprived environments and that the remedy to this situation was to provide an enriched lifestyle, value each person as an individual and enhance self-esteem. If problems persisted, a behavioral program would help retrain the person to a more adaptive behavior pattern. The belief was that these interventions would eliminate all the challenging behaviors; clinically, however, this is not always the case.
The provision of psychosocial treatment implies that some functional purpose accounts for its etiology. For example, the assumption is that if a person is provided with more alternatives to communicate his needs, to respond in different ways, and to have more meaningful daily life experiences, he will not engage in challenging behaviors. This is true for some people (with MR/DD, or without); but for many it is not true. Manic overactivity, for example, is not a functional response to the environment, it is totally driven by biological neurochemical structures and pathways. In a manic state, individuals need little sleep. Once awakened, and feeling uncomfortable, the person in the manic state may begin to roam around the house, which may attract the attention of housemates or staff. In this situation, misguided caregivers have assumed that such behavior is attention-getting and that it will respond to a behavior program.
The reality is that some behavior is involuntary. It is not under the control of the individual and may not respond to social consequences. Behavioral symptoms may be managed, but it is not the same as treating the underlying biological condition. Psychosocial and behavioral interventions may serve as containment that keeps the person safe, but only while the programmatic restrictions are in place. In many instances, pharmacological intervention may be the treatment of choice and may be the active and necessary component for healthy change.
A dysfunctional behavior may have functional significance and it may be an adaptive response at the same level. The person with MR/DD may be able to moderate either internal or external stress in the case of a psychiatric disorder by performing a dysfunctional behavior. For example, a person suffering from a major depressive episode may avoid social contact because of the discomfort and negative self-thoughts generated by socialization. The social avoidance behavior serves to reduce the discomfort. This adaptive-maladaptive response has a strong functional relationship to the environment, but it is associated with major depression. Recommended treatment usually consists of cognitive-behavioral psychotherapy in concert with anti-depressant medication.
If the target behavior is a manifestation of a psychiatric illness, then the active treatment should be directed to the underlying psychiatric illness, not just the behavioral manifestations. The treatment of first choice for a drug responsive psychiatric disorder is pharmacotherapy. Sometimes a disservice is performed by insisting that the behavior therapy is the active treatment and that the pharmacotherapy is just a containment measure necessary until the active treatment takes effect. In cases of severe depression, the person will generally be unable to initiate any self-correcting behavioral or other therapeutic measures. Once pharmacotherapy has lessened the physical symptoms associated with depression, the person will be more able to address difficulties in life and change any cognitive or behavioral habits that contribute to the depression.
If service providers are not fully trained in mental health, consultations may be misguided. If a person with MR/DD has become irritable, disruptive, and aggressive, a behavioral consultation may be sought. During the assessment, it may become apparent that the individual reacts negatively with aggression in response to task demands. Rather than jump immediately to a purely behavioral plan, a more comprehensive assessment would ask about sleep patterns, eating patterns and general mood change to assess for depression or mania. Physical symptoms could be present suggesting a medical disorder. Physical and psychiatric disorders need to be fully explored.
Cognitive limitations do not preclude psychiatric diagnosis. The problem with diagnosing criteria for mental illness is that it is based on self-reported information from people with normal intelligence. This does not imply the disorder is a function of intelligence, but the person who is non-verbal with MR/DD cannot describe negative feelings or will not express them in the typical manner.
Research has shown that self-injury is associated with depressive disorders in people with MR/DD. Self-injury, assaultive behavior and tantrums were more prominent in people with severe developmental disabilities. This prominence suggests that the greater the intellectual disability, the more undifferentiated are responses to life, perhaps because of a limited repertoire of responding.
Psychiatric disorders can be diagnosed in people with severe or profound disabilities, but they may not display the full syndrome – meet all the necessary criteria – because many of the criteria require the ability to verbalize and self-report symptoms. Partial criteria may be met and a diagnosis given. A person should not receive psychoactive medications without a DSM IV formulation Axis I – IV, even if they are severely disabled.
Bizarre behavior and psychosis
Developmental delay, limited cognitive organization, stress, and prior traumatic experiences can result in behaviors that are regularly misdiagnosed as psychotic. Behavior must be considered in a neurodevelopmental perspective prior to being diagnosed as psychotic and other possible precipitating factors must be examined. Considerations for: how organized the person’s behavior appears given latitude for the person’s developmental disabilities.
In stressful situations, people with MR/DD often become overwhelmed and suffer cognitive deterioration. A similar situation called pseudodementia, is well known in the geriatric psychiatry. Memory problems may be seen, as well as apathy and loss of hygiene or adaptive daily living skills. In these cases, an elderly person suffering from a major depressive episode shows dramatic deterioration and may frequently be diagnosed with dementia, thought to occur because of neurobiological changes in the aging brain. People with MR/DD suffer the same cognitive disintegration under stress or when suffering from a mental illness, but mental health clinicians are not all as aware of this situation, frequently misdiagnosing psychotic conditions.
From a developmental viewpoint, talking to oneself, having an imaginary friend, fantasy play and to some extent, hallucinations are not necessarily psychotic, but should be considered within the context of the person’s developmental level and present quality of life. Based on past history, a person may be having flashbacks to a former traumatic situation. Post traumatic stress may be revisited under extreme stress.
Behavioral Therapy and Pharmacotherapy
For some, pharmacotherapy is seen as a restrictive form of treatment and that there must be a behavioral plan and a timetable for discontinuing the medication. Pharmacotherapy is therapeutic and may be the first line of treatment for some mental illnesses. For major depression, manic states, and schizophrenia, pharmacotherapy must be offered and encouraged as the first treatment. For people with MR/DD, problematic behavior may be secondary to the psychiatric disorder. If this is the case, the treatment of the psychiatric disorder is the primary consideration while the behavior program focuses primarily on the containment.
For people of normal intelligence, no timetable to end medication is mandated. They can voice there opinions on options to continue or not, on side effects. If the person is tapered off from medications and begins to feel depressed again, they can tell the physician. Most people with MR/DD cannot do this and must wait until their symptoms are so difficult that they have serious decompensation. In the meantime, they may have to endure treatment aimed at making their behavior more adaptive. Such an approach is a form of disability discrimination.
Because of the advances in biological psychiatry and neurobiology, it is now understood that mental illness is strongly influenced by brain neurochemistry. Many and perhaps the vast majority of people with MR/DD may have neurobiological brain abnormalities as the cause of their disability, either due to prenatal or perinatal difficulties, the effects of toxins, illness, accidents or genetic factors. Therefore, it is more likely that these abnormalities would contribute to an increased incidence of mental illness.
Because people with MR/DD have received inadequate general habilitative care in this country until recent years, advocates have erroneously focused on pharmacotherapy as a treatment to be avoided. Today, pharmacotherapy is among the most effective treatments available for mental illness and it should be available for all individuals with intellectual disabilities.
Psychopharmacology for People With Profound and Severe Mental retardation and Mental Disorders
All classes of psychotropic medications have been shown to be useful in treating psychiatric disorders in clients with profound and severe mental retardation, but drug response tends to be more unpredictable in this population than in the general population.
Psychotropic medication classes include antidepressants, mood stabilizers, antipsychotics, anxiolytics, stimulants, and others ( eg, opiate antagonists and antihypertensives). Antiepileptic medications may also have pronounced behavioral effects.
Because diagnosis is difficult, selection of psychotropic drug treatment in clients with profound and severe mental retardation is complicated. Generally, diagnosis is based on target behaviors and symptoms, which are interrelated and guide treatment toward reasonable drug choices. Defining the meaning of the target behavior is challenging. If the client is agitated, does this stem from depression, agitated mania, agitation because of sleep disorder or psychosis, or perhaps an anxiety disorder? Drug trials are utilized because of this unclear origin of symptoms. If a drug trial is effective, it often assists in clarifying the diagnosis.
Drug history information is extremely important in developing medication trials because it can provide information that increases the possibility of success. Every effort should be made to acquire information relating to previous effective and ineffective treatments, along with the adverse effects that have occurred. Repeating ineffective drug trials needs to be avoided. In some cases, adverse effects can be minimized by using newer drugs with fewer side effects.
Due to some amount of genetic linkage, family history of mental disorders may provide beneficial information. For example, the diagnostic history of family members treated effectively for mood disorders or schizophrenia can provide insight into drug trial development for the client.
Target behaviors are identified and prioritized, baseline behavior data are collected and the client is treated symptomatically. Behaviorally defined target behaviors and qualified severity levels are extremely useful for assessing treatments. Drugs that can treat an array of symptoms are likely to be primary choices. The goals of pharmacological treatment are:
•1. keep the drug treatment as simple as possible
•2. provide the client with the greatest chance of success early in therapy
•3. use the safest drug available to avoid side effects.
Initiating Drug Treatment
Psychotropic drugs should be initiated at low doses and slowly titrated to avoid side effects. Clients with profound and severe mental retardation are frequently found to be especially sensitive to the effects of medications. Toxicity may occur at the typical dosage range used for psychiatric clients without cognitive disabilities. Additionally, drug response can be observed at lower than usual doses. If the drug is well tolerated, the drug trial may last 1 to 6 months or longer, depending on the specific drug. This period allows for an evaluation of the drug response based on the empirical data on index behaviors.
Side Effects Versus Disorders
Once a drug is initiated, it is often difficult or impossible to determine whether a client is having side effects from the medication. Clients with profound or severe retardation are not able to communicate information directly about the side effect discomfort. Staff need to be aware of the common side effects of the psychotropic medication and consider how these might affect behaviors. Regular and frequent monitoring of drug specific effects is very important in this population. Baseline laboratory values and vital signs before and after the initiation of some medications are also helpful.
Side effects may manifest as increases in target behaviors. This may occur with antipsychotic drugs that cause akathisia ( a subjective feeling of restlessness). In a client who otherwise has anxious symptoms, or becomes easily agitated, akathisia would likely cause increased rates of target behaviors. The selective seratonin reuptake inhibitors like fluoxetine (Prozac), can cause some nervousness or agitation, but this is more often observed at higher doses as can buspirone (Buspar), an anxiolytic. A client with mood symptoms and target behaviors of screaming and crying may display more if experiencing a headache as a medication side effect. Side effects may cause a person with self-injurious biting to begin banging his head because the medication is causing headaches.
Side effects of medications can also result in decreased behaviors. Sedation and fatigue are effects of many psychotropic drugs, including antipsychotics, antidepressants, mood stabilizers, anxiolytics and antihypertensives (eg beta blockers). The resultant chemical restraint from sedation is not an acceptable outcome of drug treatment.
When mild side effects occur, tolerance of them can develop over time. Common side effects like nausea, sedation, agitation and blood pressure changes often subside over time. In some cases, the doses can be decreased to lessen the adverse effect or the medication may need to be discontinued. If a drug is effective, but the side effects are a concern, another drug in the same class may be substituted.
Psychotropic drug Classes and Specific Drugs
Drugs may be used in combinations in cases of comorbidity or as augmentation treatment. It is important to remember that psychotropic medications have the potential to interact with one another, with nonpsychotropic drugs, and both prescription and nonprescription drugs. When a drug interaction is significant, it may result in treatment failure or toxic effects.
Antidepressant medications include selective serotonin reuptake inhibitors (SSRI’s), tricyclic antidepressants (TCS’s), monoamine oxidase inhibitors (MAO’s), and other miscellaneous agents. Antidepressants can be useful in treating depression, anxiety, panic, obsessive-compulsive disorders, eating disorders and sleep disturbances. TCA’s and MAO’s are not use as first line treatment due to their many side effects and interaction with foods and because they require more monitoring than the newer antidepressants.
Selective serotonin reuptake inhibitor antidepressants include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), and citalopram (Celexa). In clients with profound and severe mental retardation, these medications are considered first line treatment for depressive symptoms. Agitation, compulsiveness, impulsiveness, anxiousness, aggression, self-injury, panic symptoms, changes in appetite and sleep problems may all suggest the need for an SSRI trial. Fluoxetine (Prozac) has been shown to be effective in reducing symptoms of autism. Some of the more common side effects of SSRI’s are headache, nausea, nervousness, or sedaton, diarrhea or constipation and sexual dysfunction. If one SSRI trial fails or the side effects are intolerable, a different SSRI may succeed.
Trazodone (Desyrel) and nefazodone (Serzone) are antidepressants that can have concomitant antianxiety effects. For this reason, these drugs may be beneficial in clients with agitated behaviors. Both of these medications can also be useful for treating sleep problems. In fact, trazodone sometimes cannot be tolerated at the doses needed to treat depression due to the sedative effect. Nefazodone may be less sedating than trazodone and can actually improve sleep cycles and, thus, the quality of sleep. Notable side effects are daytime sedation, dizziness, orthostatic hypotension and alterations in heart rate.
Mirtazpine (Remeron) is a relatively new antidepressant that may have antianxiety effects. It is useful for treating clients with depressive disorder who exhibit agitation, diminished appetite with weight loss, or have sleep disturbances. Sedation , dizziness, increased appetite and weight gain are the more common side effects of mirtazapine. It has minimal anticholinergic effects (eg dry mouth, blurred vision, urinary retention and constipation).
Venlafaxine (Effexor) may be reserved for difficult to treat depressed clients or those with concomitant anxiety. Blood pressure should be monitored regularly for possible sustained increases especially in high doses or if the client has a history of hypertension. Common side effects are nausea, nervousness, somnolence, insomnia, dizziness, anorexia and sexual dysfunction.
Bupropion (Wellbutrin) is available is available in an extended form with fewer side effects. It may increase the risk for seizures, so it may be contraindicated for use with clients who have known low seizure thresholds. Clients with profound and severe mental retardation have a higher incidence of seizures, so Wellbutrin would not be a first line option in their treatment.
Antidepressant treatment, if tolerated by the client, should continue for 6-8 weeks after a therapeutic dose is reached. This provides sufficient time to collect data on target behaviors and determine if the medication is beneficial. Minimum effective doses do not apply to antidepressants, in that the maintenance dose is the initial effective dose. If others perceive that the effect of an antidepressant has ameliorated over time, options include increasing the dose, switching to a different antidepressant agent or augmenting with buspirone.
Current established mood stabilizers include lithium, valproate (eg valproic acid [Depakene] and divaproex sodium [Depakote]) and carbamazepine (Tegretol). Adjunct drug treatment might include an antipsychotic, a benzodiazepine or an antidepressant, depending on the symptoms. If traditional mood stabilizers are not well tolerated, second line mood stabilizing agents including gabapentin (Neurontin), calcium blockers (nerapamil) or trazadone may be used. Mood stabilizers can be very useful for treating bipolar disorder in individuals with profound and severe mental retardation. Treatable target behaviors may include agitation, irritability, aggression, decreased sleep, decreased appetite, self-injury, increased vocalizations, increased sexual displays, and decreased attention span. Mood swings are most easily recognized by graphing prevalent target behaviors on a chart over time. In appropriately aged females, if mood symptoms cycle monthly and are associated with their menses, the pharmacotherapy may be quite different for treating this premenstrual dysphoric disorder.
Even though lithium has been the classic mood stabilizer since the ‘60’s, valproate is now considered a first line therapy and often produces fewer side effects than either lithium or carbamazeoine. It has a wider therapeutic range, less risk of toxicity and requires less laboratory monitoring. It can also be used to simultaneously treat seizure disorders (as can carbamazepine, whereas, lithium can lower the threshold. Additionally, carbamazine can be very difficult to use because of the multitude of drug interactions involved with the individuals on concomitant drug therapies.Clients with rapid cycling or mixed state mood disorders may be more likely to benefit from valproate.
Acute manic episodes can also be effectively treated with valproate. Manic episodea with psychotic features can be treated with antipsychotics. Benzodiazepines are used to treat the insomnia and to decrease anxious symptoms.
Treatment of bipolar disorder requires maintenance doses of mood stabilizers and sometimes requires mood stabilizers in combination to prevent recurring acute episodes. It is noteworthy that a minimum effective dose does not apply to mood stabilizers. Dosages are prescribed according to blood levels maintained within a therapeutic range.
Antianxiety drugs include buspirone (Buspar), some of the antidepressants and benzodiazepines (eg, lorazepam [Ativan], clonazepam [Klonopin]). Treatable conditions in individuals with profound and severe mental retardation may be behaviorally defined nervous or anxious behaviors, panic-type behaviors, aggression or self-injurious behaviors.
Benzodiazepines should be used only in the short term as they can be paradoxical disinhibitory effect on behavior, resulting in increased agitation and aggression. They can also cause considerable sedation and impair cognitive abilities; also, if used regularly, tolerance can occur where increasing doses may be needed. However, they can be effective in managing episodic agitation or sleep problems on an intermittent basis.
Buspirone is a good first line treatment for anxiety symptoms, especially for generalized anxiety disorder. Agitation, aggression, self-injury, anxiousness or nervousness, hyperactivity and impulsiveness or compulsiveness are symptoms that might respond to buspirone treatment.
SSRI’s can be effective for treating various anxiety disorders. Paroxetine and fluvoxamine are more sedating and less stimulating than fluoxetine, sertraline and citalopram. Citalopram (Celexa) is the most selective SSRI and may be associated with fewer side effects and drug interactions. SSRI’s have proven efficacy in anxiety associated with depression, panic disorder and obsessive compulsive disorder. Encouraging findings have been reported in social phobia, PTSD, and PDD.
At this time, the atypical antipsychotics – clozapine (Clozaril), risperidone (Risperdal), olanzaoine (Zyprexa) and quetiapine (Seroquel) – are considered first line treatment as antipsychotic agents, except clozapine because of the weekly blood testing. Chlorpromazine[Thorazine], thioridazine [Mellaril], haloperidol [Haldol] are the older typical antipsychotics and are used much less. The first line antipsychotics are more effective, particularly in terms of treating the negative symptoms of schizophrenia (blunted affect, apathy, social and emotional withdrawal and anhedonia). They have less risk for extrapyramidal symptoms (akathasia, dystonias, tremors, and cogwheel rigidity). The incidence of extrapyramidal effects does increase with increased dosages.
It can be difficult at times to assess whether psychotic symptoms exist in a person with profound or severe mental retardation. When an antipsychotic is administered, orthostatic hypotension and sedation can be early side effects, but these generally subside over time. Risperidone is more likely than olanzapine or quetiapine to cause increases in prolactin levels and amenorrhea in females. Other reasons for increased levels of prolactin should be ruled out as there may be medical causes.
Some individuals, especially older clients tend to be very sensitive to therapeutic response and side effects. In individuals with severe behavioral problem, major medication changes may involve risk of increased self-injury or aggression to others.
Other medications used in combination with antipsychotics to treat side effects may be antcholinerics (eg, benztropine[Cogentin], diphenhydramine [Benadryl], trihexiphenidyl [Artane] for extrapyramidal effects or a beta-adrenergic blocker (eg, propranolol [Inderal]) for akathisia or restlessness. Benzodiazepines (eg, lorazepam [Ativan]) can be used in combination with antipsychotics for treating comorbid sleep or anxiety disorders or an antidepressant or mood stabilizer can also be used for affective disorders.
Adverse Behavioral Effects of Antiepileptic Medications in People with Developmental Disabilities
The association of epilepsy with cognitive impairment is significant. When cerebral palsy and mental retardation coexist, seizure risk is higher. Both are indicators of neurologic abnormalities. Adding antiepileptic drugs to the equation, it becomes more complicated. The idiosyncratic reactions are of the greatest concerns because they are potentially life threatening. The additive effects of combination therapy can result in toxicity for almost half of the patients receiving three concurrent antiepileptic drugs.
The inherent side effects include phenomena such as lethargy, decreased attention span, sleep pattern changes, impotency, and leukopenia. These side effects can produce their own behavioral consequences. Similarly, the dose-related adverse affects of sedation, mental dullness, ataxia, diplopia, and headache can produce behavioral effects. The ability of the cognitively impaired, mentally ill patient to articulate these concerns may be severely limited. A change in behavior may be the only way the patients have to express their concerns.
Phenytoin (Dilantin) appears essentially devoid of any significant general behavioral impact. However, in the case of people with mental retardation, phenytoin can cause significant dose-related cognitive impairment, as well as ataxia, poor coordination and dyskinesia that can consist principally of choreiform disturbances. Non-dose related effects can include significant cosmetic affects(darkening or increasing of body hair, coarsening of facial features, worsening of acne or gingival hyperplasia), which may have significant behavioral consequences. With chronic use, a consideration can be osteopenia (thinning of bones) as well as folic acid deficiency.
Significant drug interactions can also occur because of pheytoin’s significant protein binding. Drug interactions with psychotropic medications, antibiotics, or other antiepileptic drugs can result insignificant change in the level due to this saturation kinetic interaction, resulting in toxicity that may manifest only as a behavior change.
Carbamazepine (Tegretol) has resulted in many reports of favorable change. The most commonly reported changes are decreased anxiety, depression, and aggression with increased cooperation and generally improved behavior. Side effects include, double vision, cognitive viscosity, lethargy and movement disorders. Non-dose related side effects include hyponatremia, which when pronounced, can cause an exacerbation of seizures or behavioral consequences of its own. A few isolate reports of discontinuation as precipitating mania.
Valproic acid (Depakene) has demonstrated a positive behavioral effect.. Side effects include gastrointestinal upset, tremor, elevation of ammonia, some somnolence, cognitive viscosity and thrombocytopenia. Non-dose related effects include weight gain, nausea and a change in hair texture loss. From a behavioral aspect, the most pertinent concern is the confusional state that can progress to coma or stupor. There has been evidence of brain atrophy which reversed when medication was discontinued.
The barbiturates are the drugs most clearly associated with negative behavioral changes. Several studies have demonstrated increased depression, irritability, unhappiness, argumentativeness, stubbornness, or aggression. The barbiturates have also been associated with the most negative cognitive effects among the antiepileptic drugs. Other side effects of barbiturates in cognitively impaired people are self-injury, disruptive vocalizations and temper tantrums. The possibility exists of allergic dermatitis, Stevens Johnson syndrome, hepatic failure and dupytrens contractures.
Gabapentin (Neurontin) ia s new antiepileptic medication that is designed as a gammaaminobutyric mimetic. Its non dose related side effects include somnambulence, cognitive impairment hyperactivity and aggression which makes it necessary to use it cautiously with cognitively impaired people especially with a history of previous irritable or aggressive behavior.
Felbamate (Felbatol) was distributed in 1993 and used widely. Then it was discovered that this medicine has an irreversible idiosyncratic side effect, aplastic anemia. There is also possible behavioral exacerbations in patients with cognitive impairment and a past history of medicine induced behavioral exacerbations.
Other newly developed antiepileptic drugs include lamotrigine (Lamictal), topramate (Topamax), tiagabine (Gabitril).
Every anticonvulsnat medicine has behavioral consequences. The balance is between seizure control and side effects so choosing the appropriate medicine for the seizure type and epilepsy syndrome. It is prudent to avoid the barbiturates in the cognitively impaired, behaviorally challenged. Other medicines should each be considered as appropriate given their possible behavioral side effects.
Psychotropic Medications and Destructive Behavior
The purpose of administering psychotropic treatments is to improve a person’s functioning by modifying the way that he typically responds to naturally occurring events in the environment. By doing so, challenging behavior is made unnecessary and improbable.
Functional Interpretations of Destructive Behavior
A functional approach to behavioral assessment and treatment identifies factors associated with and controlling the person’s destructive behavior. These factors typically include environmental events immediately preceding or following the behavior problem as well as features of specific settings in which the behavior problem occurs.
Many of our most effective environmentally-based treatments therefore, are designed to change the way we interact with individuals with behavior problems. Knowing the function of a problem behavior is important in designing habilitative or educational program s to promote alternative adaptive behaviors while reducing problem behaviors.
Biochemical Interpretations of Destructive Behavior
There are cases, however, in which destructive behavior is neither attention nor escape motivated. There are three main neurochemical theories related to destructive behaviors – opioid receptor theory, serotonin receptor theory, and the dopamine theory.
Psychopathology, Dual Diagnosis and Functional Analysis of Behavior
Major mental illness occurs among people with mental retardation with a higher incidence than among the non-developmentally disabled comparison group. A behavioral analysis of environmental variables can extend our understanding of the way in which biological brain disorders alter people’s ability to mange their daily transactions with the world around them. In question are the primary presenting behavioral problems and learned adjustments to the environmental circumstances.
Neurobehavioral Pharmacology of Destructive Behavior
A functional diagnostic approach attempts to evaluate the most probable behavioral and biological variables that may be contributing to the behavior of concern. A behavioral function may involve a consistent pattern of staff attention to head banging which maintains the problem behavior whereas a biological function may be related tot the release of endogenous opioids when the client strikes her head. The same form of destructive behavior may be influenced and controlled by different mechanisms. Self-injury that is pain-elicited or dopaminergically-driven may appear the same (eg, hand biting), but the neurochemical mechanisms regulating each type can be very different. Problem behavior that is positively reinforced (attention from the staff) or negatively reinforced (removal of an aversive task) may respond differently to pharmacological treatments.
Therapeutic drugs influence a person’s health by modulating normal or abnormal physiological or biochemical processes. If a person prone to hypertension walks too rapidly up the stairs, it may result in his blood pressure increasing to dangerous levels. A specific medication, clonidine, increases the diameter of peripheral blood vessels and therefore reduces the degree to which blood pressure increases when the person again takes the stairs two steps at a time. In comparison, the manner in which psychotropic drugs are often prescribed to alter the destructive behavior of people with developmental disabilities seldom reflects foregoing reasoning. Instead, practitioners and family members often act as though a medication can produce a qualitatively different patient outcome independent of the cause. Inappropriate prescriptions often arise from a prevalent theoretical misconception that drugs alter brain chemicals or physiological processes and cause behavior to change independent of the environmental circumstances within which the person functions. It is true that the brain’s neurochemistry and the body’s physiology set the limits at which external environmental processes and events exert their effects, but this does not happen in a vacuum. Sometimes there is a differential effect because part of what determines a drug’s effect is the person’s current and previous environmental circumstances ( their reinforcement history). Behavioral and medical history, and current circumstances influencing their behavior are variables that create the foundations upon which drugs are able to produce their effects. By adopting a functional approach, influential behavior and environmental factors are identified that may interact with a behaviorally active medication to improve a person’s ability to function independently and adaptively in addition to reducing a person’s destructive responses to the aversive environmental stimuli and stressors. The goal is to treat the underlying behavioral and biological mechanisms, not just the appearance of the behavior problem.
Psychotropic Medications and Contextual Control of Destructive Behavior
Although different forms of destructive behavior can be influenced by discrete environmental events, such as staff demands placed on the individual, crowding, staff change, task repetition, and even stimulation arising from certain items of clothing, it is important to evaluate a broader range of environmental setting factors including the typical physical and social context setting the occasion for problem behavior, as well as events occurring within the individuals involved. This assessment would consider numerous factors including the health and physical discomfort of the individual (eg, menstrual cramps or pain from an inner ear infection), time since last meal or presence of a particular staff member.
Internal cues: rage, anxiety and panic attacks
Environmental conditions that are provocative, demanding, or otherwise, stressful can often elicit internal stimulus changes. People with mental retardation often have difficulty learning socially acceptable ways to behave to internal emotional cues. Some of these feelings, such as anger, rage, anxiety or hostility may be ameliorated after an outburst of aggressive behavior.
Monitoring Psychotropic Medication
Development of psychotropic medication:
laudanum (opium in alcohol)
chloral hydrate 1869 [sedative hypnotic]
rauwolfia serpentina 1931 [the natural basis for reserpine used to treat psychosis]
amphetamine 1937 (Adderall) [stimulant]
lithium 1949 (Lithobid, Eskalith) [antimania]
chlorpromazine 1952 (Thorazine) [antipsychotic]
meprobamate 1954 (Miltown) [antianxiety]
chlordiazepoxide 1957 (Librium)[benzodiazepine antianxiolitic]
imipramil 1958 (Tofranil) [tricyclic antidepressants]
haloperidol 1958 (Haldol) [development of antipsychotics other than phenothiazines]
sertraline (Zoloft) SSRI antidepressant
clozapine (Clozaril) [antipsychotic for treatment resistant group]
In the mid ‘70’s, it became routine to have an “annual drug holiday”. It should be remembered that the original drug holiday requirement occurred because in numerous situations, psychotropic drugs had been given in large doses for years for unknown, vague or forgotten reasons and little or no data or monitoring existed.
This has been replaced by an in-depth psychotropic review conducted at least annually in relation to the underlying condition or hypothesis, treatment stage, risk factors, dose, side effects, index behavior data, quality of life, and concurrent non-
pharmacological interventions. If reduction is deemed possible, a gradual reduction plan is developed to determine the lowest maintenance dose, which may be, but no necessarily is, zero medication.
Psychotropic Medication Definition
A psychopharamacologic medication is any drug prescribed to stabilize or improve mood, mental status or behavior. Some drugs typically classified as psychotropics may have other indications. The antianxiety agent diazepam (Valium) may be prescribed for spasticity and the stimulant methylphenidate (Ritalin) may be prescribed for narcolepsy. Similarly, drugs not typically classified as psychotropic may have psychiatric indications; such as the antiepileptic, carbamazepine (Tegretol) may be prescribed for certain affective diagnoses.
Biopsychosocial Model: postulates that biological, psychological and sociological aspects of care are interdependent and each must be acknowledged and addressed in order to provide optimal patient care.
Rational Empirical Model: the use of psychotropic medications must be based upon a psychiatric diagnosis or a specific behavioral-pharmacological hypothesis resulting from a full diagnostic and functional assessment. Specific index behaviors and quality of life outcomes must be objectively defined, quantified and tracked using recognized empirical measurement methods in order to evaluate the efficacy of psychotropic medication.
Coordinated Multidisciplinary Care Plan: psychotropic medication must be used within a coordinated multidisciplinary care plan designed to improve the individual’s quality of life. Psychotropic medication in and of itself is not a care plan. Behaviors or symptoms may worsen or improve and may do so in different settings. Behavior problems may not be entirely eliminated or may only return to previous levels, meaning that behavior or condition will still need to be addressed by the 9individual or others. Medications do not teach new skills or cognitive strategies; psychotropic medication does not prevent psychiatric relapse, it lowers the probability of relapse. A coordinated multidisciplinary care plan is important to address the interactive nature of biochemical, psychological and sociological aspects of care.
Short Term Versus Long Term Use
The length of time a person is prescribed psychotropic medication and the dose level depend on a number of factors such as the diagnosis or condition itself, treatment phase and relapse history.
Generally 3-6 months or less: the key consideration is whether the problem (and resulting diagnosis or hypothesis and treatment plan) is of a short-term nature. In this case it is considered a short-term aid while adjustment occurs or educational strategies are taught to address a situation.
Continuation (chronic use):
Generally 4-24 months depending on the condition. An initial episode of a psychiatric condition may require a longer period of treatment in order to lower the probability of relapse.
In any of these situations it is important to ensure a gradual dose reduction to ensure that any side effects are not the result of extraneous factors such as withdrawal effects, the environment, poor active treatment, other medical conditions or an undiagnosed psychiatric condition.
Maintenance (extended use):
Maintenance use is generally more than 12 – 24 months with expectation of extended or lifelong treatment.
It must be remembered that acute crisis doses or regimens are not necessarily maintenance drug and dose regimens.
The individual, if competent, or the individual’s guardian must provide written informed consent before the non-emergency initiation of any psychotropic medication and must be periodically renewed. Information should be provided orally, in writing and educationally.
They are indicative of and serve as an observable index of the underlying condition of hypothesis. Specific index behaviors are important to assist in arriving at the diagnosis, evaluating progress and the psychotropic medication efficacy over time. It is the behavior that should improve over time. Tracking objective index behaviors over time is important to determine clinical status.
A baseline is a period of time that an index behavior is measured in order to establish the frequency or severity of the index behavior. The most important aspect of a baseline is that it serves as a standard against which the efficacy of subsequent psychotropic medication is evaluated. A baseline is a mandatory part of an assessment.
Otherwise known as target behaviors. An observable index of the underlying condition or hypothesis; used to assist the prescriber of medications in diagnosis and to evaluate progress and psychotropic medication efficacy over time. As this applies to non-verbal people, clinical data collecting from behavioral observations and reports rather than traditional interviewing which has limitations. Over frequency, duration and time.
Side Effects: secondary effects of a drug that are undesirable and/or different from the therapeutic effect. ADR: any response to a drug that is noxious and unintended and that occurs at doses used in humans for prophylaxis, diagnosis, or therapy, excluding the failure to accomplish the intended purpose.
ADR classifications are: hypersensitivity – reactions related to the patient’s immunologic response; idiosyncratic – reactions manifesting themselves as an inordinate response to o a usual drug (intolerance or hyperreactivity); side effects – reactions that are unintended and unwanted, yet are known pharmacologic effects of the drug; toxic reactions – reactions that are unintended, unwanted, and are not related to the drug’s pharmacologic effects; adverse drug interactions – reactions that are due to the in vivo interaction of two or more drugs. ADR’s are usually listed in standardized pharmacy and nursing references by body areas or systems. Categories include autonomic, cardiovascular, drug interactions, endocrine, gastrointestinal, hematological, hepatic, central nervous system, neurological, ocular, respiratory, dermatological, ocular, and urinary. Side effects scales can be general or specific and they address the side effects for all medications, or specific ones, depending on which is used.
Treatment for Challenging Behaviors or Mental Health Disorders: A False Dichotomy
Psychiatric disorders occur in persons with developmental disabilities at more than four times the rate observed in the intellectually unimpaired. The incidence of psychiatric disorders increases in relation to the severity of retardation. No major psychiatric diagnoses are peculiar to certain levels of intellectual functioning.
Functional analysis of behavior: the antecedent, the behavior, and the consequences. Target behaviors can be identified, but it should be understood that target behaviors can have transitory functions.
Describing the relationship between problem behavior and maintaining functions that it serves.
Six basic functions that problem behavior may serve, organized into two classes each motivated by either social or nonsocial outcomes.
The desire to secure or maintain conditions of positive reinforcement
The desire to secure negative reinforcement associated with escape and avoidance of aversive events.
- – an individual encounters a desirable item that she cannot obtain by herself, she may produce problem behavior to influence a social partner in a way that would result in obtaining the item.
- – problem behavior may be produced when a person wishes to secure or maintain the attention of the social partner.
- – – both presume that that the desired items and attention serve as positive reinforcers.; the probability increases that problem behavior will be used in the future to obtain these outcomes because they were delivered contingently.
- – Other situations may arise that an individual is expected to engage in an activity or interact with an aversive item; in this case an individual may engage in problem behavior to escape and avoid negative reinforcement.
- – The behavior may occur in an effort to obtain the contingent removal of discomfort.
- – If soothing comfort results as a consequence for a tantrum that was originally to relieve pain, the individual may generalize his problem behavior to situations in which he would like comforting affection, but does not have pain.
Problem behaviors may begin for different reasons, but are maintained by their social effect (positive; negative reinforcement).
Considerations in the Design of Effective Treatment
Basic features of the living environment: a safe, humane environment that encourages the development and use of functional skills and likewise effectively addresses problems.
The engagement of individuals in meaningful and enjoyable interactions and activities.
Orderliness in the environment: predictability and structure of environment.
Promoting independence and competence which is supported and maintained. Effective Treatment:
Diagnosis and treatment for the biological factors and medical conditions that may be contributing to the problem, including the appropriate use of pharmacotherapy for identified psychopathology directly or indirectly associated with the challenging behavior.
Assessment and analysis of the environmental conditions and contingencies that are functional in maintaining the challenging behavior and explicit inclusion of this information in all therapeutic and living arrangements.
Alteration of environmental conditions that provoke problems are altered or removed and circumstances that set the occasion for appropriate alternative behaviors predominate in the person’s day and life.
Use of instructional methods and reinforcement systems to strengthen behavior that will functionally replace the problems and to strengthen adaptive skills that will allow the individual to function in the environments in which the problem will be less
Reduction of reinforcement for the problem, specially decreasing the magnitude and frequency of reinforcement that the challenging behavior previously produced. The decrease is a relative one, involving the differential shift of reinforcement from problem behavior to alternative elements of the individuals’ repertoire that are more benign and adaptive in a conventionally desirable way.
Arrangement of specific consequences for the problem itself if the behavior remains dangerous or disruptive despite reasonable attempts to treat it.
Systematic programming for generalization and maintenance, ensuring that the arrangements that effectively resulted in improvements in the first [place are sufficiently in place in all the settings and times to enhance the likelihood that improvement will be pervasive and durable.