Integrated Psychiatry for Individuals with Developmental Disabilities

Use of psychotropic drugs for individuals with developmental disabilities is common practice. For example, Jobski, Hofer, Hoffman, and Bachmann (2016) documented an overall median use of psychotropic drugs in 45.7% of individuals with autism spectrum disorder (ASD). Wink et al., (2018) documented that psychotropic medication usage can be over 90% for youth with ASD admitted to inpatient units. A related concern is the number of psychotropic medications utilized at one time, referred to as polypharmacy (see Masnoon et al., 2017 for further discussion regarding the complication of polypharmacy definitions). Given the concern of use with psychotropics and polypharmacy, Deb et al., (2009) provided recommendations for prescribers supporting individuals with intellectual disabilities. Examples are multi-pronged assessments; appropriate physical examinations; discussion with caregivers and the individual; and collaboration with other professionals. Although not explicitly stated, the inclusion of family, individual, and other team members aligns with an integrated treatment approach.

A simple description of integrated treatment is the cooperation of multiple professionals, caregivers, and the individual to coordinate care for all of the needs for the individual (NIMH, 2017). An integrative model is supposed to increase communication to address biological, psychological, and social needs of the individual to improve outcomes (APA, n.d.). Researchers have identified key themes of integrated teams including an identified team leader, guiding values, interdisciplinary training, and communication that promotes discussion and collaborative decision-making (Nancarrow et al., 2013). Although desirable, integrated treatment has barriers, such as pre-service training for professionals, having common goals, and lack of understanding of professionals from different disciplines (Sherman, 2013). The purpose of this article is to describe a model for integrating behavior analysts, caregivers, nurses, and psychiatry to support adults and children with developmental disabilities and co-occurring mental health conditions.

Team Members

Behavior analysts. Behavior analyst is a broad term for a professional that has been trained in and espouses the principles and practices of the science of behavior (see Skinner, 1953 and Watson, 1913).

Specifically, a behavior analyst is trained in the research methods and research outcomes demonstrating behavior is predictable and can be changed over time. A practicing behavior analyst seeks to apply these methods to improve the human condition (Baer, Wolf, & Risley, 1968). Practicing behavior analysts are often credentialed as Board Certified Behavior Analysts (BCBA), which is a master level credential comprised of university coursework, supervised fieldwork, and an exam (see for further information). Behavior analysts are adept at defining behavior to be measured to evaluate treatment outcomes, identifying treatment protocols based upon research, and training direct care workers and other caregivers to implement treatment protocols.

Caregivers. Caregiver is a broad term for individuals that provide care to another individual. This term applies not only to family members, but professionals and paraprofessionals hired to care for an individual within a service delivery model. Caregivers, especially family members, often have the most complete picture of the individual being supported given their continuous support of the individual across time. Caregivers also provide perspective on cultural norms for the individual being supported.

Nurses. A nurse is an individual who has met minimum criteria to use that title. There are various nursing credentials, but it is typically a bachelor level credential comprised of university coursework, supervised fieldwork, and an exam. Nurses ensure the team is aware of basic health information (e.g., weight, blood work) and ensures prescriptions are implemented as ordered. Although our model focuses upon nurses as active team members, other medical professionals can be added as needed. For example, participation by a neurologist might be beneficial for an individual with seizures and challenging behavior as medications used for seizures may also affect challenging behavior. The goal would be to optimize the medications for both the seizures and challenging behavior.

Psychiatry. A psychiatrist is a medical doctor who specializes in mental health needs of individuals. Psychiatrists first become licensed medical doctors, requiring university coursework, supervised fieldwork, and an exam. Following this, four years of additional supervised fieldwork specific to psychiatry is completed (see for further information). Psychiatrists utilize psychotherapy, psychosocial interventions, and medications, to name a few, to meet the needs of the individual. The psychiatrist can also assist in identifying comorbidity syndromes that may significantly impede the implementation of behavioral strategies. Simonoff et al, reported 70.8% of children studied (sample of 255 children with ASD) had at least one current psychiatric disorder including social anxiety disorder (29.2%), Oppositional Defiant Disorder (28.1%), Attention-Deficit / Hyperactivity Disorder (28.1%), Panic Disorder (10.1%), Generalized Anxiety Disorder (13.4%), and Obsessive-Compulsive Disorder (8.2%). The recognition of these specific syndromes can be extremely beneficial in addressing behaviors that are driven by psychiatric comorbidities.

Allied health professionals. The model described here often utilizes other professionals as occasion warrants. For example, many individuals have co-occurring physical needs (e.g., paralysis) complicating service delivery. Professionals such as occupational therapists, physical therapists, speech-language pathologists, and other professionals can be utilized in a consult fashion to meet the needs of the individual.

Interdisciplinary Review Team Model

The interdisciplinary review team (IRT) model was created to establish a continuum of care for individuals with complex needs. Core features of the model are multi-disciplinary team members, data-driven decision-making, and high-level administrative support. The objectives of each IRT meeting are: 1) state the current clinical status of the individual; 2) state current clinical needs; 3) foster team discussion; 4) advocate for change that maximize benefit for the individual; 5) minimize multiple treatment changes at once; and 6) minimize risk associated with chosen treatments.

The IRT model consists of a pre meeting planning process, IRT meeting, and a post meeting process. The pre meeting is an opportunity for the behavior analyst, nurse, and caregivers to identify key needs of the individual to be discussed at the IRT meeting. This meeting takes place in the 30-days preceding the IRT meeting. An IRT preparation form that documents current clinical status based upon objective data and caregiver input is completed and shared with all team members supporting the individual. The preparation states up to three discussion points, with supporting data, that guide the IRT meeting.

Interdisciplinary review team meetings occur at a frequency dictated by the needs of the individuals supported. Meetings for adult clients typically occur monthly, whereas meetings for children clients typically occur weekly. Most adults are reviewed every 90 days, whereas most children are reviewed monthly, reflecting sometimes more frequently changing needs. Individuals can be reviewed more frequently, and outside of established meeting times, if needed. Meetings are typically 30-minutes, except for special circumstances (e.g., initial review meeting). The meeting starts with the behavior analysts providing a 1-minute summary of the IRT preparation form to all team members. Based upon the discussion points the team then reviews supporting data (e.g., frequency of self-injury, health related variables, sleep patterns, lab results). Following some discussion, the individual being reviewed is invited into the review to provide information from his / her perspective (most individuals supported in this model have limited cognitive and communicative abilities, so caregiver input is important throughout the process). At this point the team proposes and decides upon action steps to address the identified areas of need. Action steps may include no changes, gather additional data, alter current treatment protocols, and alter current medications. The action step(s) chosen should maximize benefit and minimize risk. The post meeting process involves documentation of the IRT and communication to all team members, including executive leadership team members who evaluate effectiveness of the process, trends of action steps, and minimization of polypharmacy.

This model is implemented for adults and children residing in specialized residential settings. Individuals residing in this model exhibit severe and chronic challenging behavior (e.g., aggression toward others that results in injury, self-injury requiring more than first aid), present safety risks (e.g., lack of safety awareness such as walking into a street, not dressing for the weather), and complex medical needs (e.g., paralysis, dysphagia). Financial support for this model is largely covered as part of a daily residential rate that is calculated into the cost. Some third-party insurance billing does occur as well.

About the authors: Shawn P. Quigley PhD, BCBA-D, is Senior Director of Clinical Services and Professional Development – PA Division; Danielle Block MBA, BSN, RN, is Senior Director of Healthcare Services – PA Division; and Frank L. Bird MEd, BCBA, LABA, is Vice President & Chief Clinical Officer at Melmark Inc. For further information contact Shawn Quigley at, Melmark, 2600 Wayland Road, Berwyn, PA 19312, (610) 325-2929.

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