Use of functional analysis methodology in the evaluation of medication effects

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

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

Report of the ABAI Task Force on Contingent Electric Skin Shock

As a task force appointed by the Executive Council of the Association for Behavior Analysis International (ABAI), we investigated the clinical use of contingent electric skin shock (CESS) in behavior analytic treatments for severe problem behavior. We studied how CESS is used in contemporary behavior analysis, reinforcement-based alternatives to CESS, and current ethical and professional guidelines for applied behavior analysts. We recommended that ABAI uphold clients' right to receive CESS when it is restricted to extreme cases and used under rigorous professional and legal oversight. Our recommendation was rejected by a vote of the full members of ABAI, who instead endorsed an alternative recommendation, developed by members of the Executive Council, that opposed the use of CESS under any condition. Here we present for the record our report and initial recommendations, the formal statement that was rejected by the members of ABAI, and the statement that was endorsed.

A Systematic Review of Direct Assessments to Evaluate Psychotropic Medication Effects for Children With Disabilities

To evaluate effects of psychotropic medication for children with disabilities, direct assessments may offer a valuable supplement to caregiver reports. Relative to indirect assessment, direct measures of behavior can increase objectivity and sensitivity, and some have potential to isolate distinct behavioral and learning processes. We conducted a systematic, narrative literature review to identify and describe the types and qualities of direct assessment methods that have been used to evaluate effects of non-stimulant psychotropic medication for children with disabilities. We identified 50 studies and 78 direct assessments, which we organized and described using seven assessment categories. Only one study met all three direct assessment quality indicators. We use our descriptive results to highlight research trends and gaps that warrant further study.

Direct Measures of Medication Effects: Exploring the Scientific Utility of Behavior-Analytic Assessments

The purpose of the current study was to explore the scientific utility of two behavior analytic assessments (i.e., progressive ratio and demand assessments) for psychotropic medication evaluation. For a sample of 23 children with disabilities who were prescribed medication, we conducted a series of generalizability and optimization studies to identify sources of score variance and conditions in which stable estimates of behavior can be obtained. To inform construct validity, we calculated correlations between scores from each assessment and those from a standardized behavior rating scale (Aberrant Behavior Checklist-Second Edition; ABC-2). Results offer initial support for the scientific utility of progressive ratio scores. More research is needed to evaluate sensitivity to change and construct validity of scores from these and other behavior analytic assessments.

From Research to Practice: Toward the Examination of Combined Interventions for Autism Spectrum Disorders

The use of biological (i.e., medications) in conjunction with applied behavior analysis is relatively common among people with ASD, yet research examining its benefit is scarce. This paper provides a brief overview of the existing literature on the combined interventions, including promising developments, and examines the existing barriers that hinder research in this area, including the heavy reliance on RCTs. Recommendations for possible solutions, including the creation of health homes, are provided in order to move toward a more integrated approach.

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

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

Impact of antipsychotics in children and adolescents with autism spectrum disorder: a systematic review and meta-analysis

Background

The net health benefit of using antipsychotics in children and adolescents with ASD is unclear. This review was performed to provide the evidence necessary to inform the Italian national guidelines for the management of ASD.

Methods

We performed a systematic review of randomized controlled trials (RCTs) comparing antipsychotics versus placebo for the treatment of ASD in children and adolescents. For efficacy, acceptability and safety we considered outcomes evaluated by the guideline panel critical and important for decision-making. Continuous outcomes were analyzed by using standardized mean difference (SMD), and dichotomous outcomes by calculating the risk ratio (RR), with their 95% confidence interval (95% CI). Data were analyzed using a random effects model. We used the Cochrane tool to assess risk of bias of included studies. Certainty in the evidence of effects was assessed according to the GRADE approach.

Results

We included 21 RCTs with 1,309 participants, comparing antipsychotics to placebo. Antipsychotics were found effective on “restricted and repetitive interests and behaviors” (SMD − 0.21, 95% CI − 0.35 to − 0.07, moderate certainty), “hyperactivity, inattention, oppositional, disruptive behavior” (SMD − 0.67, 95% CI − 0.92 to − 0.42, moderate certainty), “social communication, social interaction” (SMD − 0.38, 95% CI − 0.59 to − 0.16, moderate certainty), “emotional dysregulation/irritability” (SMD − 0.71, 95% CI − 0.98 to − 0.43, low certainty), “global functioning, global improvement” (SMD − 0.64, 95% CI − 0.96 to − 0.33, low certainty), “obsessions, compulsions” (SMD − 0.30, 95% CI − 0.55 to − 0.06, moderate certainty). Antipsychotics were not effective on “self-harm” (SMD − 0.14, 95% CI − 0.58 to 0.30, very low certainty), “anxiety” (SMD − 0.38, 95% CI − 0.82 to 0.07, very low certainty). Antipsychotics were more acceptable in terms of dropout due to any cause (RR 0.61, 95% CI 0.48 to 0.78, moderate certainty), but were less safe in terms of patients experiencing adverse events (RR 1.19, 95% CI 1.07 to 1.32, moderate certainty), and serious adverse events (RR 1.07, 95% CI 0.48 to 2.43, low certainty).

Conclusions

Our systematic review and meta-analysis found antipsychotics for children and adolescents with ASD more efficacious than placebo in reducing stereotypies, hyperactivity, irritability and obsessions, compulsions, and in increasing social communication and global functioning. Antipsychotics were also found to be more acceptable, but less safe than placebo.

Ethical Considerations for Interdisciplinary Collaboration with Prescribing Professionals

Behavior analysts often work as part of an interdisciplinary team, and different team members may prescribe different interventions for a single client. One such intervention that is commonly encountered is a change in medication. Changes in medication regimens have the potential to alter behavior in a number of ways. As such, it is important for all team members to be aware of every intervention and to consider how different interventions may interact with each other. These facts make regular and clear communication among team members vital for treatment success. While working as part of an interdisciplinary team, behavior analysts must abide by their ethics code, which sometimes means advocating for their client with the rest of the team. This article will review some possible implications of medicinal interventions, potential ethical issues that can arise, and a case study from the authors' experience. Finally, the authors propose a decision-making tree that can aid in determining the best course of action when a team member proposes an intervention in addition to, or concurrent with, interventions proposed by the behavior analyst.

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

OBJECTIVE

The use of psychotropic medication to address challenging behavior in individuals diagnosed with intellectual disabilities is common practice; however, very few studies have examined how multiple medication use (or combination treatment) impacts the behaviors these medications are prescribed to treat.

METHOD

The current study followed eight individuals over a two-year period as they experienced changes in their psychotropic medication regimens. During that time, data from functional analyses and indirect assessments of challenging behavior were collected.

RESULTS

The results suggest that changes in psychotropic medication regimens can produce changes in functional assessment outcomes, suggesting a need for continued behavioral assessment to better inform medication practices and behavioral treatment. Of the eight participants in the study, five participants' behaviors varied in rate of responding in FAs across all medication changes. Additionally, three participants' FAs produced changes in outcomes; however, those changes were not consistent across all medication changes, that is, not every medication change yielded different outcomes from previous assessments.

CONCLUSION

This study demonstrates how the outcome of an FA can be used to monitor the effects of psychotropic medication changes, specifically when medications are combined, on challenging behavior in individuals with intellectual and developmental disabilities.

Care of children with autism spectrum disorder

Autism spectrum disorder (ASD) is both common and complicated. Many children with ASD are not identified until school age. The primary care physician (PCP) plays a vital role in recognizing the symptoms of ASD and in making referrals for definitive diagnosis. Most children with ASD also have co-occurring learning, medical, and/or mental health problems that require collaboration across the educational, medical, and mental health systems. This article reviews the symptoms of ASD, screening tools for school-aged children suspected of having ASD, and the PCP's role in identifying ASD and managing co-occurring conditions in the primary care medical home.

Clinical and pharmacokinetic evaluation of risperidone for the management of autism spectrum disorder

INTRODUCTION

Autism spectrum disorder (ASD) is a neurodevelopmental disorder that is often accompanied by psychiatric comorbidity. Although there is no medication currently available to treat the core symptoms of ASD, risperidone was the first drug to be approved for use in ASD and is still the best established psychopharmacological option for the treatment of irritability and behavioral problems in ASD.

AREAS COVERED

This article gives an overview of the pharmacokinetic profile of risperidone and a comprehensive review of treatment studies regarding the use of risperidone in ASD.

EXPERT OPINION

Ample evidence supports the short-term use of risperidone for treating irritability and behavioral problems in ASD. Risperidone also shows promise in treating symptoms often associated with ASD, such as stereotypical behavior, social difficulties, hyperactivity and cognitive problems. However, several adverse effects have been identified; most are mild or moderate and well manageable, but weight gain and metabolic changes are a considerable concern. Therefore, risperidone should in our view be seen as 'a last resort', only justified for the short-term treatment of serious behavioral problems, which have failed to respond sufficiently to behavioral interventions. Future studies should investigate long-term effects of risperidone and factors that facilitate individual risk-benefit analyses before treatment.

Self-injurious behaviour in autistic children: a neuro-developmental theory of social and environmental isolation

RATIONALE

Self-injurious behaviour is not one of the three core symptoms that define autism. However, children on the autism spectrum appear to be particularly vulnerable. Afflicted children typically slap their faces, punch or bang their heads, and bite or pinch themselves. These behaviours can be extremely destructive, and they interfere with normal social and educational activities. However, the neurobiological mechanisms that confer vulnerability in children with autism have not been adequately described.

OBJECTIVES

This review explores behavioural and neurobiological characteristics of children with autism that may be relevant for an increased understanding of their vulnerability for self-injurious behaviour.

METHODS

Behavioural characteristics that are co-morbid for self-injurious behaviour in children with autism are examined. In addition, the contributions of social and environmental deprivation in self-injurious institutionalized orphans, isolated rhesus macaques, and additional animal models are reviewed.

RESULTS

There is extensive evidence that social and environmental deprivation promotes self-injurious behaviour in both humans (including children with autism) and animal models. Moreover, there are multiple lines of convergent neuroanatomical, neurophysiological, and neurochemical data that draw parallels between self-injurious children with autism and environmentally deprived humans and animals.

CONCLUSIONS

A hypothesis is presented that describes how the core symptoms of autism make these children particularly vulnerable for self-injurious behaviour. Relevant neurodevelopmental pathology is described in cortical, limbic, and basal ganglia brain regions, and additional research is suggested.

The motivating operation and negatively reinforced problem behavior: a systematic review

The concept of motivational operations exerts an increasing influence on the understanding and assessment of problem behavior in people with intellectual and developmental disability. In this systematic review of 59 methodologically robust studies of the influence of motivational operations in negative reinforcement paradigms in this population, we identify themes related to situational and biological variables that have implications for assessment, intervention, and further research. There is now good evidence that motivational operations of differing origins influence negatively reinforced problem behavior, and that these might be subject to manipulation to facilitate favorable outcomes. There is also good evidence that some biological variables warrant consideration in assessment procedures as they predispose the person's behavior to be influenced by specific motivational operations. The implications for assessment and intervention are made explicit with reference to variables that are open to manipulation or that require further research and conceptualization within causal models.

Towards the prevention of behavioural and psychiatric disorders in people with intellectual disabilities

Intervention for behavioural and psychiatric disorders in people with intellectual disabilities often only takes place once these conditions are well established and more resistant to change. As an alternative, this paper promotes a public health prevention model and maps out opportunities for intervention at primary, secondary and tertiary levels. The resulting model is partly derived from generic research into these issues and partly on specific evidence on interventions for people with intellectual disabilities; it also contains more theoretical considerations. The additional research that is necessary to demonstrate the efficacy of the interventions identified is also considered. Central to this proposal is a greater integration of issues for people with intellectual disabilities within much broader policy and research agendas.

Treatment of psychopathology in people with intellectual and other disabilities

OBJECTIVE

To review the psychosocial, pharmacological, and other treatments of psychopathology in people with intellectual disabilities (IDs), autism, and other developmental disabilities (DDs).

METHOD

Systematic reviews and meta-analyses of psychosocial, pharmacological, and other treatments for people with DDs are reviewed.

RESULTS

There is strong evidence for applied behaviour analysis (ABA) and other behavioural treatments of some forms of psychopathology. There is little good evidence to support the effectiveness of cognitive-behavioural therapy, cognitive therapy, sensory interventions, and other forms of psychosocial interventions. Recently, more randomized controlled trials (RCTs) of psychopharmacology have been published, especially with people with autism spectrum disorders. Most RCTs were for externalizing behaviour problems, rather than for psychopathology. These RCTs offer only preliminary support for the effectiveness of pharmacotherapy. No evidence was found for the effectiveness of other biological treatments.

CONCLUSIONS

Current research supports the use of ABA and other behavioural interventions for some forms of psychopathology. Evidence for the effectiveness of other interventions is limited or absent.

Controlled evaluation of the effects of hyperbaric oxygen therapy on the behavior of 16 children with autism spectrum disorders

Hyperbaric oxygen therapy (HBOT) has been used to treat individuals with autism. However, few studies of its effectiveness have been completed. The current study examined the effects of 40 HBOT sessions at 24% oxygen at 1.3 ATA on 11 topographies of directly observed behavior. Five replications of multiple baselines were completed across a total of 16 participants with autism spectrum disorders. No consistent effects were observed across any group or within any individual participant, demonstrating that HBOT was not an effective treatment for the participants in this study. This study represents the first relatively large-scale controlled study evaluating the effects of HBOT at the level of the individual participant, on a wide array of behaviors.

Psychotropic drug treatments for people with autism and other developmental disorders: a primer for practicing behavior analysts

Many people with developmental disabilities receive medications prescribed to improve behavior. This manuscript overviews the psychopharmacology of developmental disabilities and considers how practitioners can assist in improving the quality of the pharmacological treatments that their clients receive.

The status of pharmacotherapy for autism spectrum disorders

The use of pharmacologic agents as a component of treatment for children and adults with autism spectrum disorders is common and a substantial body of literature describing controlled and open-label clinical trials now exists to guide clinical practice. Empiric evidence of efficacy of risperidone, methylphenidate and some selective serotonin re-uptake inhibitors for maladaptive behaviors commonly associated with autism spectrum disorders has increased substantially in recent years. Preliminary controlled trials of valproate, atomoxetine, alpha-2 adrenergic agonists and olanzapine are promising. In addition to traditional psychotropic medications, investigators have examined the potential role of a variety of agents with glutamatergic or cholinergic mechanisms, and the results warrant further investigation. Although psychotropic medications are effective in treating some important associated behaviors, evidence of significant impact on the core features of autism spectrum disorders is very limited.