Marc Weeden , Ph.D , BCBA-D Juniper Gardens Children’s Project University of Kansas

1. Strategies for Maximizing Psychotropic Drug Treatments for People with Autism and Other Developmental Disabilities: A Primer for Teachers and Parents Marc Weeden, Ph.D, BCBA-D Juniper Gardens Children’s Project University of Kansas

2. Overview • History/Prevalence • Off-Label Prescribing • Behavior Analysis • Identify Target Behavior (s) • Record and Graph Relevant Data • Interpret Data • Communicate Data to Appropriate Parties

3. History/Prevalence • Psychotropic drugs – medications prescribed with the intent of improving an individual’s mood, cognition, or overt behavior • 1950’s – Thorazine • Approximately 40-50% people with autism receive at least one psychotropic medication (e.g., Green et al., 2006; Goin-Kochel, Myers, & Mackintosh, 2007)

4. Risperidone (Risperdal) • A wide variety of psychotropic drugs are prescribed for people with autism and other developmental disabilities • Antipsychotics are the most prescribed (Poling et al., 2004) • Approved by the FDA in 2006 for treating “irritability” in people with autism between the ages of 5 and 17 • Only drug that is FDA-approved as a psychotropic medication for people with autism

5. Off-Label Prescribing • Any other drug that is prescribed to improve the behavior of people with autism, the use is “off-label” • The drug is prescribed for a purpose other than that for which it is specifically FDA-approved • Accepted medical practice if there is reasonable scientific evidence that a given drug is effective for a particular application

6. A Word of Warning • Drugs do not selectively reduce problem behavior • Appropriate behavior may be reduced, too • Drugs may interact with other non-pharmacological interventions

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

8. Applied Behavior Analysis • Discipline concerned with analyzing and modifying human behavior • Procedures based on basic principles of behavior are used by professionals and/or paraprofessionals to change behavior in socially significant ways (Miltenberger, 2004)

9. Characteristics of ABA • Behavior is the subject of study • Labels are de-emphasized • Behaviors of interest are clearly defined • Variables that control behavior are identified and modified • Behavior change is measured over time • Hypothetical underlying causes of behavior are avoided

10. Applications of ABA • Organizational Behavior Management • Health • Safety • Developmental Disabilities • Behavioral Pediatrics • Drug Addiction • Recycling • Education • Behavioral Pharmacology

11. How to Identify Target Behavior (s) • Behavioral Excess • Behavior to be decreased in frequency, duration, or intensity • Example: Smoking • Behavioral Deficit • Desirable behavior to be increased in frequency, duration, or intensity • Example: Exercising, Studying

12. Defining the Target Behavior (s) • Definitions must be specific and related to actions • Example from Major League Baseball: Unsportsmanlike behavior • Cursing, throwing the bat, kicking the dirt

13. Defining the Target Behavior (s) • Internal states (sad, angry, frustrated) are avoided • Internal states can’t be observed or measured by others

14. Defining the Target Behavior (s) • Labels (“a bad sport”) are not used because they do not describe an individual’s actions • Definitions can vary from person to person • Precise definitions help to ensure data accuracy

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

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

17. How to Record and Graph Relevant Data • Dimension of behavior – some quantifiable aspect of a behavior of interest • Frequency – number of times a behavior occurs in the observational period • Duration – how long a behavior takes to occur from beginning to end

18. How to Record and Graph Relevant Data • Baseline – record the behavior prior to implementing the intervention • Allows for comparison and gives a clearer picture as to the effectiveness of the medication (is the behavior already decreasing due to a teacher intervention before the meds are given?) • Not always possible, as in the case of self-injurious behavior

19. How to Interpret Data • Risperidone intervention • Example 1: Talk outs is the behavior of interest • Defined: Speaking at an audible level while teacher is providing instruction to the entire class • Use frequency as method of recording • Data recorded during math class each by paraprofessional

21. How to Interpret Data • You can say that the intervention was successful if all other sources of variability can be ruled out (e.g., other intervention started at the same time) • Be aware of side-effects (e.g., sedation)

22. How to Interpret Data • Methylphenidate (Ritalin) • Example 2: On-Task is the behavior of interest • Defined: Participating in an assigned task (e.g., completing math problems) • 20 minute observation period • Duration • Recording with a stop watch how long child is on-task

24. How to Communicate Results • Make the graph easy to understand • Meet as often as possible with the circle of support (e.g, parents, teachers, paraprofessionals) • Let the data guide treatment decisions • The MD will be able to better adjust or discontinue medication usage with accurate data

25. Risperidone Side Effects • Dry Mouth • Increased Appetite • Weight Gain • Sedation • Constipation • Blood Pressure Changes • Dizzyness • Headache • Tremors

26. Risperidone Side Effects • Make a plan to evaluate side effects • For example, closely monitor the weight of the person taking the drug (e.g., once per week) • Are they asking for more to drink and is this causing problems? • Might be difficult for an individual with autism to report adverse effects

27. Summary • Define target behavior precisely • Select an appropriate system of measurement • Communicate results • Make a plan to evaluate side effects • Let the data guide treatment decisions

28. Concluding Comment • Psychotropic drugs are neither good nor bad • Medications can be helpful, harmful, or inconsequential • Good psychopharmacology, like any good intervention, is individualized and data based • The task will rarely be easy, but it will always be worthwhile

29. Contact info • mweeden@ku.edu