I am the parent of a 29-year-old man who has a long history of aggression that has been controlled with heavy amounts of multiple medications. I am not sure if this is realistic, but do medications used for behavior ever get reduced? If so, how can that happen? Is there anything I should look for in a residential setting that might help identify one that would be open to assessing whether medication reductions could happen when warranted? 

Answered by Frank Bird, MEd, BCBA, LABA, CDE, Jill Harper, PhD, BCBA-D, LABA,
Maria Wizboski RN-C, BSN, CDE®, Haley Steinhauser, PhD, BCBA-D, LABA
Melmark New England

Psychotropic Medications and AutismThis is an excellent question, and one that is important to highlight. As part of our reply, we will offer some examples that illustrate what can happen when a team identifies medication reduction as a goal. Often, challenging behaviors are managed, in part, with the concomitant (i.e., simultaneous or concurrent) use of psychotropic medications (i.e., medications that treat psychiatric symptoms such as anxiety or mood disorder). Over time, and especially with multiple escalations in behavior, multiple medications may be simultaneously administered. Teams and families can be reluctant to alter or reduce medications, especially if the behavior is stable. Polypharmacy has been defined in various ways, but generally refers to the long-term and simultaneous use of multiple medications by the same individual (Masnoon et al., 2017). It has been estimated that the majority of individuals with ASD are treated with medications, with some sources estimating that up to 75% of those on medications are on more than one simultaneously (Vohra et al., 2016).

Examining the research literature illustrates just how central this issue is to treatment and how often it comes up in treatment teams. Polypharmacy is common, as multiple medications are often concurrently taken (Vohra et al., 2016). Interestingly, the published research on the use of psychotropic medications in individuals with autism is not as robust as would be expected, given the prevalence of their use (Bertelli et al., 2016; Poling et al., 2017; Siegel & Beaulieu, 2012). The state of the literature is weak, with few well-controlled studies (Poling et al., 2017).

Nevertheless, it is common that behavioral issues are so severe that medications are judged to be appropriate and likely to have a positive impact (e.g., Lunsky et al., 2018). Many have suggested that there is a need for more examination of the effects of medication on behavior (e.g., Weeden et al, 2010), skill acquisition, and other aspects of functioning (mood, appetite, sleep, etc.). In addition, there is a need to examine the process and the monitoring of polypharmacy (Stortz et al., 2014).

Eventually, there may be better guidance and decision trees regarding the initiation of psychotropic medications. Indeed, some progress in this area has been made, as different decision trees help clinicians focus on issues of safety, the extent to which the medication is evidence-based and effective for a particular behavior, and the degree to which the medication is compatible with other elements of treatment (Brodhead, 2015; Newhouse-Oisten et al., 2017). In the interim, it is important to address polypharmacy in clients who are already in this predicament. One of the primary concerns is side effects. Side effects can be severe, and they can be permanent. Hence, risks exist for long-term use, especially for certain medications. Several strategies may be explored in these situations, including medication dosage reductions and drug holidays. Continual monitoring helps identify problematic side effects, issues associated with prolonged use, and the need for reduction strategies.

Vital Oversight Components

Often, the process of evaluating medication needs occurs in the context of a residential placement, where medical and behavioral expertise are readily available for ongoing analysis. The availability of 24-hour monitoring and an interdisciplinary team enables systematic assessment of needs and methodical adjustments and probes. The process of medication monitoring requires several elements. When these elements are in place, it is sometimes possible to consider medication reductions. These elements are: (a) coordinated and collaborative involvement of all members of an interdisciplinary team, including the individual served, medical providers, nurses, behavior analysts, and special education professionals, (b) parent-guardian participation and active involvement in the team, (c) data-driven decision making, and (d) high-level administrative support. A full commitment to data-based decision-making within an interdisciplinary team can help steer a goal to reduce psychotropic medication. At all times, decisions are guided by behavioral impact, and the team alters the course based on objective data.

Case Studies

We are presenting the cases of several clients who were able to be totally or significantly weaned off psychotropic medications over time. In all cases, they were identified as being overmedicated and/or excessively co-medicated. The team believed it was realistic, appropriate, and necessary to reduce medications. Please note that this is not always the case and that medications are commonly maintained or added, depending on individual needs. It is important not to overgeneralize these examples. At the same time, it is also important to illustrate that polypharmacy should and can be reduced in some cases.

With four individuals (Adam, Bill, Charles, and Donald), medication dosages were gradually reduced, and the medications were eventually discontinued, while problem behavior steadily decreased to near-zero frequencies. The fifth student (Edward), who had been prescribed three psychotropic medications before admission, was able to safely tolerate sizable dosage decreases. In all cases, the interdisciplinary process focused on adding-discontinuing psychotropic medications and altering dosages based on behavior and health considerations. For example, in three students (Adam, Bill, Charles), the month with the highest frequency of challenging behaviors resulted in a dosage increase, which was then subsequently decreased as behavior stabilized. With another student (Donald), one medication (lithium) was increased in the month with the highest frequency of self-injury, increased for two months, then decreased after a second medication (risperidone) was introduced. Both medications were gradually decreased and successfully discontinued.

Important take homes from these cases

Ultimately, these data show a few things that are important to emphasize.

    1. Dosage and medication reductions/eliminations are highly individualized, sometimes possible, and often non-linear. This is an area where idiosyncratic variability is extreme; the next step can be determined only by the examination of the impact on that one specific individual. Evaluation over time is key, as there may be irregular patterns before a stable impact emerges. Additional adjustments may be needed.
    1. Data guide the decisions and help the team objectively evaluate the impact of dosage adjustments. The commitment to objective verification is universal. Subjective opinions are inevitable, but changes are made only in response to verifiable information. This key commitment to data-based decision-making helps to orient all members of the team and serves as a compass in making treatment decisions.
    1. Change often takes place slowly, in some cases over years. As is usually the case, it took years for each of these clients to get to where they were, and it took years to explore ways to improve their situations. Patience is essential as the team examines trends over time, and as the stability of those changes are evaluated. Such long-term data is helpful to examine, as it presents real-world information on the timeline of lasting behavioral change. Note that sometimes changes need to be made quickly; it is always important to balance concerns over side effects with goals for therapeutic effects. Medication monitoring is a complex and comprehensive process, and individual reactions must be continually assessed.
    1. The organizational commitment to a collaborative interdisciplinary team model is an essential component. The setting embraced evidence-based treatment and data-sensitive progress monitoring. Medical expertise was valued, and the team was guided by a commitment to an interdisciplinary treatment model (Brodhead et al., 2018; Cox, 2019). Members of the team spoke a common collaborative language, sought knowledge from each discipline, achieved consensus on goals, and emphasized objectivity in decision-making.

Revisiting the Question

Obviously, medications are often prescribed with good results among children with ASD, and they can be a vitally important part of treatment. However, reducing and eliminating medication is desirable whenever it is feasible. Assembling an interdisciplinary team to assess the need for medication and the readiness for medication reductions is important; such a team helps to manage the therapeutic, health, and safety concerns associated with psychotropic medications.

It is impossible to say whether medication reduction or elimination is feasible for your loved one. As these cases illustrate, this is an extraordinarily complex and highly individualized process. Nevertheless, in looking for a placement where this can be evaluated, several characteristics come to mind. Look for a placement with an interdisciplinary model; coordination of care is especially important for complex cases. Second, look for a placement with a value on data-based decision-making. Objective data can help guide the team forward, even in the most ambiguous and complicated circumstances. Third, although it can be extremely difficult, try your best to be patient. Also remember that there is no clear ‘one size fits all’ where particular medications consistently change certain behaviors across all individuals. It can take years for these issues to be adequately assessed and for a path forward to emerge.

References

Bertelli, M. O., Rossi, M., Keller, R., & Lassi, S. (2016). Update on psychopharmacology for autism spectrum disorders. Advances in Mental Health and Intellectual Disabilities, 10, 6-26. https://doi.org/10.1108/AMHID-10-2015-0049

Brodhead, M. T. (2015). Maintaining professional relationships in an interdisciplinary setting: Strategies for navigating the non-behavioral treatment recommendations for individuals with autism. Behavior Analysis in Practice, 8, 70-79. https://dx.doi.org/10.1007%2Fs40617-015-0042-7

Lunsky, Y., Khuu, W., Tadrous, M., Vigoud, S., Cobigo, V., & Gomes, T. (2018). Antipsychotic use with and without comorbid psychiatric diagnosis among adults with intellectual and developmental disabilities. The Canadian Journal of Psychiatry, 63, 361-386. https://doi.org/10.1177/0706743717727240

Madden, J. M., Lakoma, M. D., Lynch, F. L., Rusinek, D., Owen-Smith, A. A. Coleman, K. J., Quinn,V. P., Yau, V. M., Qian, Y. X., & Croen, L. A. (2017). Psychotropic medication use among insured children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 47, 144-154. DOI 10.1007/s10803-016-2946-7

Masnoon N., Shakib S, Kalisch-Ellett L., Caughey G.E. (2017). What is polypharmacy? A systematic review of definitions. BMC Geriatr. 17(1):230. doi:10.1186/s12877-017-0621-2. PMID: 29017448; PMCID: PMC5635569.. PMID: 29017448; PMCID: PMC5635569.

Newhouse-Oisten, M. K., Peck, M. K., Conway, A. A., & Frieder, J. E. (2017). Ethical considerations for interdisciplinary collaboration with prescribing professionals. Behavior Analysis in Practice, 10, 145-153. https://doi.org/10.1007/s40617-017-0184-x

Poling, A., Ehrhardt, K., & Li, A. (2017). Psychotropic medications as treatment for people with autism spectrum disorders. In J. L. Matson (Ed.), Handbook of treatments of autism spectrum disorder (pp. 459-476.). Springer International Publishing/Springer Nature. https://doi.org/10.1007/978-3-319-61738-1_25

Siegel, M., & Beaulieu, A. A. (2012). Psychotropic medications in children with autism spectrum disorders: A systematic review and synthesis for evidence-based practice. Journal of Autism and Developmental Disorders, 42, 1592-1605. https://doi.org/10.1007/s10803-011-1399-2

Stortz, J. N., Lake, J. K., Cobigo, V., Quellette-Kuntz, H. M. J., & Lunsky, Y. (2014). Lessons learned from our elders: How to study polypharmacy in populations with intellectual and developmental disabilities. Intellectual and Developmental Disabilities, 52, 60-77. http://aaiddjournals.org/

Vohra, R., Madhavan, S., Sambamoorthi, U., St.Peter, C., Poe, S., Dwibedi, N., & Ajmera, M. (2016). Prescription drug use and polypharmacy among Medicaid-Enrolled adults with autism: A retrospective cross-sectional analysis. Drugs-Real World Outcomes, 3(3), 409–425. doi:10.1007/s40801-016-0096-z

Weeden, M., Ehrhardt, K., & Poling, A. (2010). Psychotropic drug treatments for people with autism and other developmental disabilities: A primer for practicing behavior analysts. Behavior Analysis in Practice, 3, 4-12. https://doi.org/10.1007/BF03391753

Citation for this article:

Bird, F., Harper, J., Wizboski, M., & Steinhauser, H. (2023). Clinical Corner: Can psychotropic medication be safely reduced? Science in Autism Treatment, 20(5).

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#Adults #ChallengingBehavior #MedicalProviders #Multidisciplinary #Psychologists #Residential

 

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