a behavioral diagnostic paradigm for integrating behavior analytic and psychopharmacological interventions

1: A Behavioral Diagnostic Paradigm for Integrating Behavior Analytic and Psychopharmacological Interventions David A. Pyles, PhD W. A. Howe Center

3: Problem Behavior by People with Developmental Disabilities Aggression Self Injury Property Destruction Pica Rumination Noncompliance

4: Mental Health Disorders in People with Developmental Disabilities Schizophrenia Depression Anxiety Disorders Bipolar Disorder OCD

5: Incidence of Psychotic Spectrum Disorders in People with DD Higher than general population? Same as general population? Lower than general population?

6: Incidence of Psychotic Spectrum Disorders in General Population 3 to 5%

7: Incidence of Psychotic Spectrum Disorders in People with DD 1 to 3% Approximately 35 to 50% of people with DD receive psychotropic medication 65% of psychotropic medications prescribed are antipsychotics

8: The forgotten question… Why is this happening?

9: The certainty with which convictions are held tends to vary inversely with the depth of knowledge on which they are based. Eisenberg (1964)

10: Those who fall in love with practice without science are like a sailor who enters a ship without a helm or a compass, and who never can be certain whither he is going. Leonardo da Vinci

11: When you can measure what you are speaking about, and express it in numbers, you know something about it; but when you cannot measure it, when you cannot express it in numbers, your knowledge is of a meager and unsatisfactory kind: It may be the beginning of knowledge, but you have scarcely, in your thoughts, advanced to the stage of Science. --William Thomson

12: Translation If you have not measured something, you don’t know much about it. Make it your business to know about what you are trying to change. Data represent the best means for making decisions and assessing treatment Only collect data used for decision making

13: A single accurate measurement is worth a thousand expert opinions. -Grace Hopper

14: Functional Categories of Behavior Social consequences Attention Escape Tangibles Nonsocial variables Automatic reinforcement Pain/discomfort Physiological conditions Allergies Neurological conditions Mental health disorders

15: Functional Categories of Behavior Learning history Poor modeling Reinforcement history Inadequate prosocial repertoire Inadequate communication repertoire

16: Hypothesis testing People often seek answers without knowing the questions Clinicians should focus on determining the relevant issues Developing reasonable hypotheses depends upon Relevant data Relevant assessments

17: Hypothesis testing Once hypotheses have been developed, practitioners can weigh the evidence to determine which to test first

18: Relevant concerns in intervention selection Most supporting evidence all factors being equal, hypotheses with most support should be tested sooner Least contradictory evidence It is as important to assess contradictory evidence as supportive evidence Most reliable evidence A reliable assessment should be given greater weight than an unreliable one

19: Relevant concerns in intervention selection (cont.) Speed of results All things being equal, it is reasonable to test a hypothesis that yields quick answers Restrictiveness of intervention All things being equal, test hypotheses using nonintrusive methods prior to testing those involving intrusive procedures

20: Staging Interventions Multiple hypotheses can be developed simultaneously Multiple assessments can be conducted simultaneously Only ONE intervention can be tested at a time

21: Given equal explanatory power… Which intervention should be implemented first? Medical or Behavior Program? Medical or Psychotropic Medication? Behavior Program or Psychotropic Medication?

22: Behavioral Diagnostics Determining the cause of a problem, then treating it Medical causes Environmental causes Biological/biochemical causes Interactions of the above

23: In case you were wondering… When you know everything, you are awarded a Bachelor’s Degree When you realize you don’t know anything, you are awarded a Master’s Degree When you realize you don’t know anything and neither does anyone else, you are awarded a Doctorate

24: It’s often best to begin by assuming you don’t know anything about the problem at hand…

25: How to proceed? One way to address the problem is to develop a decision matrix This way, there is some structure for interdisciplinary teams to proceed to develop practical, ethical, and effective interventions The decision matrix should be based on a hypothesis testing model The focus then is on developing relevant questions and collecting reliable data

26: Medical Intervention

27: Medical Intervention Before implementing behavioral intervention, rule out medical conditions This medical examination is usually not the admission one Psychiatrist may be involved in this process if neuropsychiatric condition (e.g. Fragile X Syndrome) is suspected Data used for evaluation are the same as those designed earlier Evaluation is an ongoing process

28: Example Ruth scratches her skin when it gets too dry What do you recommend?

29: Behavioral Intervention

30: What is Functional Assessment? Function means cause in science Functional assessment is a means of determining why a behavior occurs There are several different means of conducting a functional assessment

31: Why Conduct a Functional Assessment? Knowing behavioral function allows interventions to be specifically tailored to specific situations It results in individualized programs It helps practitioners avoid a ‘hit and miss’ approach to treatment Function based interventions are more effective than those that are not It provides an ethical alternative to the Least Restrictive Treatment approach

32: How is a Functional Assessment Conducted? Indirect Assessment Descriptive Analysis Probe Analysis Experimental (Analog) Analysis

33: How Does Functional Assessment Relate to Treatment? Interventions are based on why the problem behavior is occurring Antecedents, establishing operations, setting events, and consequences must all be consistent with behavioral function Ensure intervention does not reinforce problem behavior Ensure intervention does reinforce prosocial behavior

34: Selection of Replacement Behaviors Based on functional assessment What SHOULD the person do? Consequences remain necessary Replacement behavior/positive intervention must be equally low effort and efficient as aberrant behavior At least equal amounts of reinforcement must be available for replacement behavior as aberrant behavior Must eventually tap into naturally occurring sources of reinforcement

35: Examples of Interventions Functional communication training Teaching person to wait Social skills training Relaxation training/anger management training Noncontingent reinforcer delivery

36: Other Considerations in Program Development Baseline rate of behavior Make the replacement behavior as efficient as the dysfunctional behavior May need to tolerate a less severe topography of the behavior Engaging environments reduce maladaptive behavior Teach person to make good choices Modify program if no progress Pick your battles

37: Behavioral Intervention

38: Behavioral Intervention Construct operational definition for each targeted behavior/symptom Conduct functional assessment Passive behavior management is preventing behavior problems by addressing antecedent stimuli Active behavior management is changing behavior by acting directly upon the consequences Interventions must be based on data obtained from functional assessment Evaluation is an ongoing process

39: Example Kate teases others, which gets them upset. Caregivers lecture her and tell her to stop, but the problem is getting worse:

40: Why do you think she is teasing them? Here are some possible solutions Determine the preferred kind of attention Initially, give her lots of attention noncontingently Provide attention only when she is behaving appropriately Attention should never provided when she is exhibiting problem behavior Teach her to obtain attention appropriately

41: Example Jon bangs his head and screams when his workshop becomes too loud and disruptive

42: Why do you think he is doing this? Here are some possible solutions Determine what he is escaping Determine why he is escaping Teach him a proper way to refuse or delay request, to leave the situation, or to obtain a break Do NOT use timeout procedures in this situation

43: Psychopharmacological Intervention

44: Psychopharmacological Intervention Review available medical and behavioral data Observe, interview, and examine to determine if behaviors/signs conform to mental health disorder Determine how to clarify diagnosis and provide most appropriate treatment Develop operationalized behavioral criteria for signs/symptoms If new admission, evaluate current medication regimen for side effects and appropriateness

45: Psychopharmacological Intervention If medication is ineffecacious, consider alternative regimens Diagnostic evaluation and medication effectiveness is based upon objective data and is an ongoing process

46: What Should the Focus of Treatment Be? Increase independence Teach the person to control his/her own reinforcers Teach self-control Improve prosocial behavior Teach person to negotiate problematic environments successfully Bring behavior under control of naturally occurring reinforcers

47: Focus of treatment (continued) Reduce frequency of behavioral episodes Reduce severity of behavioral episodes Reduce reliance on restrictive procedures Decrease injuries to the person/others Successfully addressing the previous four translates to reduced risk for the person and others

48: Summary Process is complex Focus should be on asking the right questions Disciplines must work together Change one variable at a time One discipline should not make repeated interventions without involving other disciplines if treatment is ineffective