Benefits of an integrated approach when addressing complex medical and behavioral needs

I am concerned that my son has an underlying medical problem that may explain some of their behaviors. Do you have any advice for a parent of a very complex individual who may have both medical and behavioral difficulties? How are such individuals treated? What kind of care is required? How do I ensure my son gets what he needs? He is already residentially placed, and they are very expert. However, I just want to know what I should be expecting or requesting.

Answered by Lauren Carter, MEd, BCBA, LABA, Emily Chin, PT, DPT, Maria Wizboski, RN-C, BSN, CDE®, and Mary Jane Weiss, PhD, BCBA-D
Melmark
The Need for Multidisciplinary Care

Benefits of an integratedapproach when addressing complex medical and behavioral needs?

Photographed by cottonbro studio (pexels.com)

This is a very important question, as those with significant challenges such as your son need specialized care, which can be exceedingly difficult to obtain. When there are significant medical challenges along with behavioral issues, highly specialized, coordinated care is of paramount importance. This type of approach allows interdisciplinary teams to efficiently address multiple presenting needs simultaneously and comprehensively (Boivin et al., 2021). This collaborative process requires trust, respect, and clearly defined and equitable roles, in addition to commitment and accountability. It requires each discipline to have comprehensive knowledge of their specialty, as well as an understanding of the other team members’ roles, including training, experience, and scope of practice (Boivin et al., 2015; Brodhead, 2015; LaFrance et al., 2019; Slim & Reuter-Yuill, 2021).

In theory, all clients benefit from interdisciplinary collaboration. In some instances, however, such collaborative care is essential for survival, optimal health, and overall quality of life. When the needs of the individual require specialized expertise from multiple disciplines, a collaborative team approach is needed. It is important for there to be a focus on the values underscoring the team’s approach, the roles and responsibilities of each member, and on the quality of interprofessional collaboration and teamwork (Slim & Reuter-Yuill, 2021).

A Complex Case as an Example

The following case study highlights the importance of an interdisciplinary approach to obtaining a medical diagnosis for an individual with a complex behavioral profile that is related to an underlying medical condition. It may serve as an example of some of the most important elements of integrated, multidisciplinary care. We have bolded some of the most critically important elements of assessment and intervention in complex cases.

The individual was a 20-year-old male with a diagnosis of autism spectrum disorder (ASD) and attention deficit and hyperactivity disorder (ADHD). He was non-verbal and used an AAC (Augmentative Alternative Communication) device to communicate his wants/needs throughout his day. This individual attended a residential and school program (Melmark), where the primary methodology is applied behavior analysis. For the duration of his school and residential days, the individual was taught in a 2:1 staff to student ratio due to a challenging behavior profile. The individual received allied services in the areas of speech and language pathology, occupational therapy, and physical therapy.

In terms of behavioral profile, the individual engaged in inappropriate use of materials (i.e. throwing, swiping, crumpling), displayed difficulty remaining seated during academic instruction, demonstrated inappropriate and/or unsafe behaviors when moving from one area to another and when seated near peers, minimizing opportunities to participate in group instruction, and engaged in kicking towards walls, dropping to the floor to engage in head directed self-injury, hitting head to walls, and attempting to access unsafe areas. Historically and currently, this individual engaged in high rates of challenging behaviors (e.g., aggression, self-injury, disrobing, property destruction [i.e., throwing objects], and ritualistic behaviors) which limited his access to some environments, social interactions, and academic programming. He also demonstrated resistance in the form of aggression and self-injury when access to a preferred activity/item or ritualistic behavior was restricted and/or blocked and demonstrated limited safety awareness during transitions (e.g., kicking dangerous items, knocking over items, climbing on furniture). This individual did not demonstrate awareness/understanding of risks to himself or others when engaging in these topographies of challenging behavior.

To gain a more comprehensive understanding of the individual, other aspects of their daily routine and health were examined. In this case, the individual, at times, presented with decreased sleep patterns, illness, or injury as a result of self-injury. During these times, interventions were modified to ensure the safety of the individual. For example, during times of decreased sleeping patterns or illness, the individual was given opportunities to take a nap during the day. During times in which the individual had sustained an injury (i.e., fracture, hematoma, concussion), modified intervention protocols were written and trained with all staff working with the individual to ensure the safety of the individual and staff to prioritize healing and no further injury.

Medical History

It is crucial to get a comprehensive medical history for the individual, with a high level of specificity about historical challenges and current presenting problems. Part of this process involves identifying which therapists (i.e., OT, PT, speech) should evaluate the individual. In this case, the individual’s baseline presentation (prior to noticeable changes in the presenting profile) supported referrals to and ongoing services from occupational therapy, physical therapy, and speech and language pathology. The occupational therapist noted left hand dominance with equal use of the upper extremity, shoulder complex, and fine motor skills. The physical therapist noted symmetrical gait pattern (equal step length, step height, heel contact, and toe clearance), midline trunk and reciprocal motion of hip/pelvis, variable gait pattern directly related to interfering behavior of reaching/kicking or attempts to gain access to items/areas while walking. The speech and language pathologist noted a typical swallow pattern with no signs of distress or aspiration. These evaluations assisted the team in understanding the individual’s complex needs and ensured a consistent approach across providers and disciplines. It is always the case that the individual’s complex and comprehensive needs are best articulated by a series of evaluations across disciplines.

It is essential that the individual is closely monitored in an ongoing manner by clinicians from multiple disciplines. Regarding our case, in September of 2022, noticeable changes in the individual’s presenting profile were noted. Specifically, the occupational therapist noted significant atrophy of the right upper extremity muscle bulk, decreased active range of motion and strength within his right upper extremity, and increased muscle tone within the left wrist and fingers. The physical therapist noted decreased control of the right side leading to an ataxic variable gait pattern with right sided foot drop, an increase in needed external support (leaning on staff) only on the left side (most intact side), and less tolerance for walking (with increases in flopping behavior, unclear if for pain). The speech and language pathologist noted coughing after the intake of thin liquids, and wet vocal quality when asked to sustain the vowel /a/ after swallowing of thin liquids.

Quick assessment is essential when there are changes in physical functioning or medical indicators. In this case, a variety of evaluations and appointments were scheduled to ensure that these dramatic changes in adaptive functioning were fully assessed. Appointments were made with dentists, oral surgeons, neurologists, physiatrists, rheumatologists, and orthopedists. An MRI showed that the brain stem was smaller on the left than on the right. A physiatrist ensured that aquatic PT could be consistently given. Seizure activity was also noted, and anti-seizure medication began. Issues with wisdom teeth and chipped teeth were fixed, reducing the potential for infection or pain to contribute to the individual’s distress. It is important to address all medical and dental issues that are identified to reduce the layers of complexity and help to identify remaining variables.

Follow-up and Protocol Development

Any changes in the individual’s presentation warrants assessment and the introduction of protocols that are systematically implemented and evaluated. In this case study, motor deterioration was clear and may have been secondary to abnormalities in brain structures and to seizure disorder. The following are protocols/services that were put into place to decrease the continued decline in motor movements. Physical therapy, occupational therapy, speech therapy, and nursing worked collaboratively to develop a checklist (Figure 1) to assess the individual’s presentation each morning. All staff working with the individual were taught to use this checklist and when to alert therapists/nursing if a change was noticed. This checklist assessed the individual’s ability to follow motor imitation with his face, arms, as well as his walking gait. Due to weakness noticed in right extremities (hand/arm/leg), the individual was fitted for a leg brace and a wrist brace. Given some behavioral concerns with toleration, the Board Certified Behavior Analyst (BCBA) collaborated with the physical therapist and occupational therapist to ensure that systematic toleration programs were implemented to gradually build stamina and tolerance. The individual’s environment was also modified to allow for a more open area to sit and move around, with a student desk and chair available for completing seated work tasks. The individual also began wearing a hard sided helmet with a face shield in 2021, due to head directed self-injury. This helmet continued to be worn to ensure no further injury to the head. Adaptations to current therapy services occurred. Physical therapy was added to the individual’s Individualized Education Plan (IEP). This allowed for the physical therapist to implement and monitor exercise programming and stretching toleration. In addition, aquatic therapy was recommended and implemented through a local YMCA.

During all medical interventions, collaboration with the behavioral team members is also vital. Through all the assessments, medical appointments, and inter-professional collaborations, the individual was closely monitored by the consulting psychiatrist through consultation/review of current medication regime, review of behavioral data/graphs, and videos of presenting symptoms. This was vitally important when the individual displayed movements that could be attributed to seizure activity, which needed to be examined to rule out any psychiatric medication side effects.

As is the case with all biological and behavioral interactions, the combined expertise of all disciplines ensures adequate oversight. Additionally, the addition of new evidence-based procedures can be added, with systematic analysis of its potential merits. In the case illustrated here, new evidence-based and compatible approaches ensured that there was support and direction to address the changes within the individual (Newhouse-Oisten et al., 2017). The more complex the individual’s needs, the greater the need for interdisciplinary care (LaFrance et al., 2019).

Figure 1:

Facial Movements
Puff up cheeks	___ Same as Picture ___ Different than picture ___ Unable to perform
Stick tongue out	___ Same as Picture ___ Different than picture ___ Unable to perform
Tongue to left and right	___ Same as Picture ___ Different than picture ___ Unable to perform
Smile	___ Same as Picture ___ Different than picture ___ Unable to perform

Upper Extremity Movements
Lift both arms overhead	___ Same as Picture ___ Different than picture ___ Unable to perform
Lift both arms out to the side	___ Same as Picture ___ Different than picture ___ Unable to perform
Lift both arms outstretched in front palms up	___ Same as Picture ___ Different than picture ___ Unable to perform
Lift both arms outstretched in front palms down	___ Same as Picture ___ Different than picture ___ Unable to perform
Shrug Shoulders	___ Same as Picture ___ Different than picture ___ Unable to perform

Lower Extremity Movements Maximal – needs full assistance from staff to complete the task Moderate – requires light physical from staff to complete the task Minimal – requires touch cue or shadow support for brief assistance from staff to complete the task or reaches for staff for support throughout walking Independent – no hands-on support needed with the task
	AM	PM	Comments
Sit to Standing (from floor)	___ Maximal ___ Moderate ___ Minimal ___ Independent ___ Unable to perform	___ Maximal ___ Moderate ___ Minimal ___ Independent ___ Unable to perform
Walking	___ Maximal ___ Moderate ___ Minimal ___ Independent ___ Unable to perform	___ Maximal ___ Moderate ___ Minimal ___ Independent ___ Unable to perform
	Additional Notes:

Conclusion

Individuals with disabilities often encounter barriers with access to care. These barriers include the individual’s inability to communicate, persist, and advocate for their own needs (Malik-Soni, et al., 2022). Given this, they often require others to serve as their advocates. Such advocacy becomes even more essential when needs are complex and/or the individual’s medical and behavioral profiles change. Other barriers include limited training to medical professionals in providing services to individuals with disabilities (Bruder, et al., 2012). Collaboration across all disciplines helps to ensure proper advocacy for appropriate evaluation and access to comprehensive care under these conditions. Within this case, all disciplines provided summaries of relevant information to caregivers when they were not able to attend appointments. Perhaps most vital to this approach, all disciplines were integrated into every assessment checkpoint, ensuring comprehensive and thorough evaluation.

Partnership with the family was also essential and helped ensure that the family members advocated directly for their loved one. Given that multiple individuals within this organization were on the team, it was important to ensure that all members communicated with each other, and that one member was identified as the point of contact for the parents, ensuring efficient and accurate delivery of information and opportunities for the parent to advocate.

Many parents do not have the resources and/or know what to advocate for; this family requested the assistance of staff. To ensure successful visits to each appointment, proper staffing was always secured. In addition, a team member attending the appointment brought his medical record to appointments and worked to limit the need for unnecessary imaging. This staff member could also reference the medical record to answer questions related to previous appointments, test results, etc.

It is important for organizations to embrace an interdisciplinary model for individuals on the spectrum, especially when their needs are complex and when there is a clear interface between biological variables and behaviors. Creating an openness to an active, collaborative, partnership across disciplines helps ensure adequate assessment and treatment, and ensures that the individual, the family, and staff are supported in their advocacy and care for clients.

Regarding our question, it is our hope that your setting will provide a multidisciplinary model of both assessment and intervention. An integrated model of care can make all the difference in identifying and meeting complex needs, in maximizing their outcomes and quality of life, and in ensuring their care is comprehensive and held to the highest standards.

References and Additional Resources:

Boivin, N. E., Blevins, H., Norton, V., Pierce, C., Stone, A., Weiss, M. J., & Whelan, C. (2015). Characteristics of interdisciplinary practice. Southeast Education Network Newsletter (Winter 2015/2016), 106-108.

Boivin, N., Ruane, J., Quigley, S. P., Harper. J., & Weiss, M. J. (2021). Interdisciplinary collaboration training: An example of a preservice training series. Behavior Analysis in Practice, 14(4),1223-1236. doi: 10.1007/s40617-021-00561-z. Erratum in: Behavior Analysis in Practice. 2021 May 3;14(4):1237.

Brodhead, M. T. (2015). Maintaining professional relationships in an interdisciplinary setting: Strategies for navigating nonbehavioral treatment recommendations for individuals with autism. Behavior Analysis in Practice, 8(1), 70-78. 10.1007/s40617-015-0042-7.

Bruder, M. B., Kerins, G., Mazzarella, C., Sims, J., & Stein, N. (2012). Brief report: The medical care of adults with autism spectrum disorders: Identifying the needs. Journal of Autism and Developmental Disorders, 42, 2498-2504.

Krauss, M. W., Gulley, S., Sciegaj, M., & Wells, N. (2003). Access to specialty medical care for children with mental retardation, autism, and other special health care needs. Mental Retardation, 41(5), 329-339.

LaFrance, D. L., Weiss, M. J., Kazemi, E., Gerenser, J., & Dobres, J. (2019). Multidisciplinary teaming: Enhancing collaboration through increased understanding. Behavior Analysis in Practice, 26, 709-726. doi: 10.1007/s40617-019-00331-y. PMID: 31976281; PMCID: PMC6743510.

Malik-Soni, N., Shaker, A., Luck, H., Mullin, A. E., Wiley, R. E., Lewis, M. S., Fuentes, J., & Frazier, T. W. (2022). Tackling healthcare access barriers for individuals with autism from diagnosis to adulthood. Pediatric Research, 91(5), 1028-1035.

Newhouse-Oisten, M. K., Peck, K. M., Conway, A. A., & Frieder, J. E. (2017). Ethical considerations for interdisciplinary collaboration with prescribing professionals. Behavior Analysis in Practice, 10, 145-153. doi: 10.1007/s40617-017-0184-x. PMID: 28630818; PMCID: PMC5459773

Ruble, L. A., Heflinger, C. A., Renfrew, J. W., & Saunders, R. C. (2005). Access and service use by children with autism spectrum disorders in Medicaid Managed Care. Journal of Autism and Developmental Disorders, 35, 3-13.

Slim, L., & Reuter-Yuill, L. M. (2021). A behavior-analytic perspective on interprofessional collaboration. Behavior Analysis in Practice, 20,1238-1248. doi: 10.1007/s40617-021-00602-7.

Citation for this article:

Carter, L., Chin, E., Wizboski, M., & Weiss, M. J. (2024). Clinical Corner: What are the benefits of an integrated approach when addressing complex medical and behavioral needs? Science in Autism Treatment, 21(6).

Other Related Clinical Corner Articles:

Related Research Synopses:

Related ASAT Reviews:

Related ASAT Articles:

Related Media Watch Letters:

#Collaboration #Multidisciplinary #MedicalProviders #Residential #SocialWorkers

What are the Benefits of an Integrated Approach when Addressing Complex Medical and Behavioral Needs?