Review of the Quick Guideline for Collaborative Interventions for Behavioral Issues

April 13, 2010 edition

Best Practices Collaborative Process involves 4 stages

•Stage 1 – Is the behavior problem related to physiological event/ illness?

•Stage2- Evaluate if there is a significant behavior problem

•Stage 3 – Evaluate the problem in relation to the environment

•Stage 4: Evaluate if psychiatric problem prior to prescribing medications

Stage 1 – Is the behavior problem related to physiological event/ illness?

•Get medical professional evaluation for medical conditions or contributions ▫Prior to consultation with physician for

evaluation of medical cause or contributions gather information

▫During the medical consultation ask the physician to evaluate any possible medical conditions

Common medical conditions that contribute to behavioral issues

• Vision or hearing deficits • Thyroid function • Celiac disease • Sleep apnea • Anemia • Gastro esophageal reflux or other GI issues• Constipation • Depression • Anxiety • Dental issues• Sinus infections or allergies• Seizure activity• Hormonal/gynecological issues –menstrual cycle

Stage 1 cont.

▫Look for drug effects including possible toxic effects from current medications (overdose) and side effects or interactions, include routine lab work, electrolyte levels

▫Evaluate information regarding weight loss/gain, sleep and activity levels

▫Consider drug interactions that may precipitate or aggravate aggression or self injury , agitation or psychomotor activity

Actions Steps for team If a medical condition is possible cause/contributes to behavior problem or symptoms

•Access treatment for any medical conditions

•Teach consumer to request medical care for problems in the future.

•If related to current medication -Have medical team discontinue and/or substitute medication.

•If related to seizures - Have medical team review anticonvulsant regimen to establish better seizure control.

Stage2- Evaluate if there is a significant behavior problem

If Not physiological/medical or if resolving medical issue does not resolve situation/symptoms there may be a significant behavior problem

May not be a significant behavior problem if the following are true-

▫The person’s behavior can be described as developmentally typical behavior, Could the support person have a misconception that there is a problem?

Educate Support person, assist to respond therapeutically▫The support person is experiencing Stress (may be

related to care of person or issues in their life – economic, work, relationships, etc)

Provide Support with stress management, respite, counseling, support group

▫There has been a recent change in support person? If so it is possible that the Level of problem is the same and the support person is less tolerant?

IF the above situations are true and assistance has not resolved the issue, consider issues below

May not be a significant behavior problem if the following are true:

▫The person’s behavior can be described as developmentally typical behavior, Could the support person have a misconception that there is a problem?

Educate Support person, assist to respond therapeutically▫The support person is experiencing Stress (may be

related to care of person or issues in their life – economic, work, relationships, etc)

Provide Support with stress management, respite, counseling, support group

▫There has been a recent change in support person? If so it is possible that the Level of problem is the same and the support person is less tolerant?

IF the above situations are true and assistance has not resolved the issue, consider issues below

Is the Problem Transient? May be a temporary problem if there is or recently was some event such as:

•A physical illness of the individual with Intellectual Disabilities or in family or support persons

•There has been a temporary life disruption such as a move, new housemate, introduction of new family member (baby, marriage of significant other, return of war veteran, etc)

•Death in the family

IF any temporary disruption/event has occurred and the problem behavior is new or recently escalated

•provide support for temporary issue as below and evaluate in a few months.

consider respite, provide support person with ability to respond empathetically to individual, possible very short term medication

Stage 3 – Evaluate the problem in relation to the environment•Complete functional behavioral

assessment and Develop Behavior Support Plan

Functional Behavioral Assessment

•Identify target behaviors/symptoms and begin baseline data collection and completion of the ABC checklist by team

Functional Behavioral Assessment cont.• Observations in multiple settings looking at patterns of A-

B-C and motivational events• Interview with persons who know individual for looking

for common patterns with description of situations in which no problems, in which there typically are problems, what a typical day involves, choices available, history of interventions tried

• Record review-look for similar information as above• Circumstantial patterns associated with a particular

setting or time of day that behavior regularly occurs (at work shop but not home, with one staff not others, around meals

• Recent changes in physical or social environment (move, staff, schedule)

Design behavior support plan

•Related to likely functions of behavior and environmental variables/interactions that may contribute to the target symptoms/problem behaviors

•Teaching, encouraging and motivating with positive contingencies emphasis

•Safety Crisis plan to address how to maintain safety when problem behavior occurs

Behavior Support Plan• Obtain consent, consensus of team and implement

plan,• Monitor implementation and collect data

regarding behavior and plan implementation,• Allow sufficient time for plan to take effect

(minimum 2 weeks) – re-evaluate if not effective, revise and implement

• Look at hypothesis• Confirm fidelity of implementation and

measurement• Validate effectiveness of reinforcement schedule

and type

Stage 4: Evaluate if psychiatric problem prior to prescribing medications to address target symptoms:

•Complete full psychiatric evaluation and•Obtain baseline of target symptoms for

two weeks, •Get functional assessment completed

and •Behavior support plan implemented for

at least one month •Prior to prescribing medications to

address target symptoms

Stage 4 cont.

•Complete psychiatric assessment – meet criteria for DSM diagnosis?

•Complete risk – benefit assessment with team

•Review current prescription and OTC medications and current health status for interactions or complications by psychotropic medications

•Obtain consent from guardian and assent from person (and family)

Stage 4 cont.

•Develop and document treatment plan including BSP, monitoring and medical treatments along with monitoring methods for effects of medications, expected effects of medications on target symptoms, diagnosis if appropriate, contraindications and tapering and elimination of medication plan

• Prescribed medications should be used to treat a specific condition and targeted symptoms of that condition

• Prescribe psychotropic at lowest effective dosage for trial period (length to be determined by time required for medication effects for target symptoms, continue data collection for target symptoms, document plan in record, implement psychotropic medication effects monitoring protocol (side effects)

• At end of trial period compare baseline to trial period for target behaviors-if desired change in target symptoms, continue medications with monthly reviews for next 3 months. Re-evaluate for need in 6 months, drug holiday or taper in 1 year or less.

• Monthly review for new prescription and every three month for ongoing

If person is currently prescribed psychotropic medications and above process has not been completed:

▫Begin best practice medical evaluation with extra emphasis on side effects and complications possible from psychotropic medications, evaluate effects of medications and titrate if poly pharmacy

If person is currently prescribed medications and process has not been completed

▫Complete functional assessment and target symptoms measurement ,

▫ Implement behavioral support plan based on hypothesized functions of behavior or contributions of environmental variables and motivational events

▫Establish baseline behavior and target symptom measures with medications in place and analyze changes in data as changes in medications made

▫ If Behavior support plan already developed Evaluate for fit with hypothesized functions of behavior Insure implementation with accuracy Evaluate data collection and accuracy Revise and implement as necessary

If poly pharmacy:

▫Protocol for evaluation of need and discontinuation of multiple medications

During the psychiatric consultation:

• Ask the psychiatrist to evaluate accurate diagnosis? Are target symptoms compatible with diagnosis?

• Is the recommended psychotropic consistent with diagnosis and target symptoms addressed by it?

• What benefit does psychiatrist anticipate?• What would the consequence of not receiving the medication

be?• How will the med interact with other drugs including OTC, is

it contraindicated?• What are the adverse side effects to be expected/monitored

for/what to do about them if noticed?• When will the effect of the drug be seen how will changes be

monitored?• Will initial dose likely change, what will be the schedule for

increases what should occur if dosage is missed?• Additional resources psychiatrist may know to address issue?• Does psychiatrist have impression that the family or team

expects a pharmacological solution?

After Psychiatric Consultation

• Monitor and document the effects of medications and environmental interventions

• Observation of changes in the individual and response to medications

• Does medication seem to accomplish its intended purpose?

• Have changes in status been noticed including judgment, orientation, memory, problem solving, motor abilities, sleep, diet, energy, interests, relating to others, and general behavior?

• Tardive dyskensia formal monitoring by trained individual