T08 - NADD

1 10/20/2013. Assessment tools to promote effective Brief Overview services and treatment of people with IDD and Behavioral Health Needs START programs utilize various assessment tools and strategies to assist in promoting effective services and Part II treatment. We will review the use of the following tools and methodologies: Presented by: o The Aberrant Behavior Checklist Members of the National START Network located in o The MEDS. North Carolina, Arkansas, Virginia o Emergency/crisis assessment strategies, and and New Hampshire o Data collection and reporting at the START. Therapeutic Resource (Respite) Center ABC. Aman & Singh 1986. Aberrant Behavior Checklist Informant scale: caregiver independently (ABC) completes the form Application within START Model Aims to capture specific behavioral symptom areas Jill Hinton, Center for START Services, National Team Member Developed on normative data from institutions and later data for group homes Anne LaForce, LPA.

2 NC START Central, Clinical Director Widely used, over 250 published papers using the ABC. Using informant rating scales ABC form has 58 items & 5 subscales Informant: Subscale Number Items How well do they know the person? Irritability 15. Are they eager to do this work for you? Lethargy 16. Do they have the academic skills Stereotypy 7. required? Hyperactivity/Noncompliance 16. Did they read all the material? Inappropriate Speech 4. Is the setting within which they complete the scale quiet with no pressures? Are you available for questions? 1. 10/20/2013. Steps to use ABC Interpreting the ABC. ABC is best interpreted as an indicator of types of Explain the importance to informant problem behaviors and then used for tracking Insure the informant knows the person well improvement or worsening of these behaviors Provide quiet space, time, writing area, ruler for ease of completion Three key subscales can suggest a possibility of Provide Individual Items with Specific Examples in particular psychiatric conditions: sheet protector o Irritability depression, bipolar disorder, ADHD, PTSD.

3 Thank informant and tell the results and how they will be o Lethargy depression used in simple terms o Hyperactivity-Noncompliance depression, bipolar disorder, ADHD. ABC issues How Does START Use the ABC? It captures behavioral data and does not capture much Provides a baseline initially about the individual in other ways Utilized quarterly, provides a longitudinal perspective of Some language on the pink sheet is not modern and behavioral issues you might explain this to the informant Used in combination with other data, can provide useful Despite its limitations it is the most useful and important information about service needs rating scale for ID. Other Factors .. Family Stressors (illness, loss of job, divorce, etc). Changes in caregiver Two Case Studies .. Change in living situation Medications Illustrating Effective Use of Change in day services ABC. Utilization of planned respite 52.

4 Medical Issues 2. 10/20/2013. Case 1: John - 25 y-o male Case 1: Missy - 24 y-o female Diagnosis: Schizophrenia, Paranoid Type and Mild ID. Diagnosis: Autism, Mild ID, and Jacobsen Syndrome Initial 2nd 3rd 4th Initial 2nd 3rd 4th Irritability 10 0 6 19 Irritability 23 18 10 8. Lethargy 8 0 2 1 Lethargy 27 27 8 1. Stereotypy 2 3 1 2 Stereotypy 14 14 1 2. Hyperactivity-Noncompliance 16 9 3 25 Hyperactivity-Noncompliance 33 35 8 9. Inappropriate Speech 5 4 2 5 Inappropriate Speech 12 8 3 2. ABC Results ABC Results 30. 40. 25 35. 52 109 102. 20 30. 25. 15. 16 20. 10 30. 15 14 15 22. 5 10. 0 5. Initial 2nd 3rd 4th 0. Initial 2nd 3rd 4th Irritability Lethargy Stereotypy Hyperactivity Inappr Speech Irritability Lethargy Stereotypy Hyperactivity Inappr Speech Medication Side Effects and Monitoring Getting Too Many Antipsychotics Many group-home residents with mental Anne Desnoyers Hurley, retardation are receiving psychotropic University of New Hampshire-IOD medications that may be doing far more harm than good.

5 Denise Hall, LCSW MAIA SZALAVITZ 2011. Virginia START Director, Region III. 16. Anne Desnoyers Hurley, UNH. Major Issues Major Issues Issue: Solution: High rate that medicines, particularly antipsychotics, Empower support carers and families to monitor and are prescribed for challenging behavior discuss side effects in decision-making about the efficacy of medicines 17. Anne Desnoyers Hurley, UNH. 18. Anne Desnoyers Hurley, UNH. 3. 10/20/2013. Antipsychotic Medication USA Antipsychotic ID Studies General Population Tsiouris et al. 2013 NY State 45%. de Kuijper 2010 Netherlands 32%. Holden & Gitlesen 2004 Norway 2008 Domino & Swartz USA Lott et al. 2004 California 32%. Spreat 2000 et al Oklahoma Robertson et al 2000 UK 56/27/17%. (1997) Branford et al. 1995 UK 44%/13%. (2005) Jacobson 1988 NY Intagliata & Rinck, 1985 Missouri 45/29%. 19. Anne Desnoyers Hurley, UNH. Side Effects Studies ID in UK.

6 (Adverse Events) Monitoring audit side effects monitoring Metabolic Syndrome Performed by physician Conversation with patient Tin et al. 2008, 185 SGA majority-- no MS. significant monitoring o (self-report). Patton et al. 2011, 2,319 pts-- 40% no evidence of Examination MS monitoring Studies & laboratory tests Griffithes et al, 2010, 178 pts Specific exams (AIMS) takes extra time o No reference to side effects 30%. Most people with ID cannot inform well o Only MS monitoring was weight for 60%. Matson Evaluation of Drug Side START Medication Side Effects Effects (MEDS) Project Matson & Baglio 1998. MEDS: 90-item informant-interview scale: chart review MEDS administered to all guest at the START. also necessary Center programs Severity and duration the last 2 weeks Information shared with family, referral source, GP. 3- point scale (severity: 0 = no problem, 1 and psychiatrist mild/moderate, 2 severe/profound)and (duration: less, Training for all staff on medications and side effects 1 mon.)

7 , 1 month year, more than 1 year) We are starting a conversation about efficacy and Inter-rater reliability & internal consistency , side-effects (informed consent). test-retest (Matson, Mayville, Bielecki, Barnes, Bamburg, & Baglio, 1998). 4. 10/20/2013. MEDS (Matson & Baglio, 1988). MEDS Matson & Baglio 1998. Cardiovascular Subscale 9 categories, each 5-14 symptoms 1. A sudden loss of strength or fainting (1) cardiovascular and hematological 2. Trouble breathing or shortness of breath (2) gastrointestinal 3. Rapid breathing (tachypnea). (3) endocrine/genitourinary 4. Chest pain (4) eye/ear/nose/throat 5. Irregularity of the heartbeat (5) skin/allergies/temperature 6. Abnormal frequency of heartbeat (Circle one: bradycardia / tachycardia). (6) CNS-general 7. Subnormal arterial blood pressure (hypotension). (7) CNS-dystonia 8. Persistent high blood pressure (hypertension).

8 (8) CNS-parkinsonism/dyskinesia 9. Abnormality in white blood cell count (9) CNS-behavior/akathisia Case Study: Jim Jim'. 's Medications 58 year old Male Quetiapine 100 mg Diagnosed with Schizophrenia, Paranoid Type, Mild ID Levothyroxine 150. Placed in special education classes in first grade Risperidone 2 mg bid both expressive and receptive delays. Benztropine 5 bid Clonazepam 4 tid Family marital conflict and alcoholism Ranitidine 50 bid Lived at home until sister moved out Antacid 500 tid First hospitalization at the age of 31 (3 yrs), poor sleep & Divalproex sod 125 tid appetite, agitation, anxiety, suicidal ideation diagnosed Buproprion SR 150 mg bid with schizophrenia, paranoid type Alprazolam tid Lived in ALF 20+ yrs closed due to violations Moved into current GH almost 2 years ago Matson Evaluation of Jim'. 's Medical Problems Drug Side Effects (MEDS). Study compared to controls Norm Jim Hypothyroidism (1) cardio /hematological 2.

9 Kidney disease (2) gastrointestinal 3. Hypertension (3) endocrine/genitourinary 2. GERD (4) eye/ear/nose/throat 5. (5) skin/allergies/temperature 3. Weight (6) CNS-general 22. Tardive Dyskinesia (7) CNS-dystonia 1. Severe hearing loss in his left ear (8) CNS-parkinsonism/dyskinesia 11. (9) CNS-behavior/akathisia 4. TOTAL 53. 5. 10/20/2013. Rogers vs. Okin 1975 Contacts MEDICAL LAW-THE RIGHT TO REFUSE Anne Desnoyers Hurley ANTIPSYCHOTIC DRUG TREATMENT: o SUBSTANTIVE RIGHTS AND o PROCEDURAL GUIDELINES IN. MASSACHUSETTS Denise Hall o Rogers v. Commissioner of the Mental Health Department, 390 Mass. 489, 458 308. Johnny Matson - MEDS. (1983) o 31. Anne Desnoyers Hurley, UNH. Calls Initiate Screening Emergency Assessments Get there as soon as possible! Partnerships are built by actual follow-through Michelle Kluttz, BS. NC START West, Director Sometimes what is asked for isn't what is needed James Vann, MHP Different assessment tools available VA START Region 1, Director Assessment Tools Assessment Tools (cont.)

10 (see handouts). Recent Stressors Questionnaire (RSQ). Crisis assessment form: o Helpful in determining what is going on with the o Talk to the individual and to people who know person by looking at different issues the person the individual to obtain information has encountered o Speak with hospital/crisis personnel to get o Should be completed with someone who knows different perspectives the person well in order to obtain accurate o Obtain as much information as possible information o Completed at times of crisis and intake and repeated at 6 month intervals 6. 10/20/2013. Things to Consider Things to Consider (continued). Look at the presenting problem (why did you receive phone call?) E. Duration of current problem Find out what happened recently: F. Diagnosis A. Psychosocial (moves, changes in routine, loss, G. Find out why caller thinks this happened, why changes in staff, family, work/school) now?