RCPA 2014

1. Integrating Behavioral and Pharmacologic Interventions: Treating People with Psychiatric Disorders and IDD RCPA 2014 • Cheryll Bowers-Stephens, M.D.,M.B.A. • Chief Medical Officer PerformCare

2. System of Care Overview • The goal of this specialized program was to interrupt the cycle of multiple hospitalizations and institutionalization by promoting community inclusion and expert care. • The program utilized: • Expert staff. • Outpatient Assertive Community Treatment (ACT) program serving ages 2 to 22. • Specialized inpatient adolescent unit serving ages 13 through 18. • The program was part of the ICF-MR Waiver Demonstration Project, and included longitudinal data.

3. DNP Service Model Components of the DNP service model include: • Utilizing learning-based, structured teaching approaches. • Encouraging healthy, prosocial behaviors while promoting social inclusion and reintegration, or stabilization, in the community. • Adapting therapies to the cognitive abilities and developmental needs of the individual.

4. DNP Service Model (Continued) • Fully integrating family and school into the treatment. • Promoting social skills development, and building upon the youth’s personal goals, strengths and competencies. • Promoting interagency support and coordination. • Community collaboration and support are also key to the success of the program.

5. Evidence-Based Practices Utilized • Some of the therapeutic techniques utilized by the specialized inpatient unit include: • Integration of behavioral and pharmacological interventions. • Functional analysis and behavioral modification (i.e., applied behavioral techniques, cognitive behavioral therapy and behavioral therapy). • Continuity of care. • Modified Linehan approach (dialectical behavioral therapy). • Relaxation training.

6. Prevalence of Psychotropic Usage by Drug Class (Prior to admission)

7. Diagnostic Errors Noted During the Course of Treatment • Diagnosis of psychosis based solely on invalid self-report of auditory hallucinations. • PTSD was often misdiagnosed as psychosis. • PTSD was sometimes incorrectly diagnosed as conduct disorder. • Bipolar disorder was often diagnosed as conduct disorder.

8. Integrating Pharmacotherapy and Behavioral Therapy Step-Wise Approach • Applied behavioral analytic approach. • Functional behavioral analysis and identification of target behaviors; pharmacologic inventory. • Linking target behaviors to DSM-V diagnosis. • Literature review identifying evidenced-based treatments. • Behavioral therapy to target behaviors mediated by environmental factors. • Pharmacotherapy to target biologically mediated behaviors

9. Case Example: 13-Year-Old Presents with Diagnosis of Schizophrenia

10. Baseline Assessment: H = Herpetic Lesion, M = Menses

11. Diagnostic Clarification: PTSD/Cyclical Mood Disorder Implementation of Cognitive Behavioral Therapy and Pharmacotherapy

12. Additional Programs Supporting the IDD Populations • The following slides will highlight several programs that actively advocate for higher-quality treatment interventions for the IDD population. It is important that all programs have the ability to complete the following core competencies: • Conduct a comprehensive biopsychosocial assessment — typically the first intervention offered — which can assist the clinician with differential diagnosis, as well as accurate diagnosis of current symptomatology. • Demonstrate the willingness and ability to collaborate with physicians regarding any secondary medical diagnoses which may complicate treatment. • Correctly administer and interpret psychological testing with an IDD population.

13. American Academy of Child and Adolescent Psychiatry (AACAP) • In order to best serve the IDD population, the AACAP advocates for: • The creation of a Community-Public Psychiatry certification. • Certification will improve the quality of individual care for people in community-public settings through training improvements, and by furthering the development of the field of Community-Public Psychiatry. • Retrieved from https://sites.google.com/site/aacpcertification/home

14. AACAP (Continued) • Additional goals include: • Increase interest for members in training to pursue careers or training in public psychiatry. • Professionally support community-public psychiatrists through credentialing. • Define essential knowledge and skills of the field. • This includes developing standardized treatment protocols for this population. • Retrieved from https://sites.google.com/site/aacpcertification/home

15. AACAP (Continued) • Supplementary goals include: • Encourage residency training programs to strengthen public and community psychiatry training. • Recognize community psychiatrists with years of providing quality psychiatric services. • Improve cohesiveness among community psychiatrists through defined professional identity and community education. • Retrieved from https://sites.google.com/site/aacpcertification/home

16. AACAP Advocacy • AACAP advocates for the following treatment protocols: • Replacement behavior training. • Social skills training. • Psychoeducation on IDD and other atypical developmental needs. • Individual, group and family therapy. • Behavioral Interventions that are developmentally appropriate. • Concrete goals for treatment that are collaboratively developed by all team members. • Treatment delivered by clinicians with experience working with this population. • Interventions that are developmentally appropriate. • Retrieved from https://sites.google.com/site/aacpcertification/home

17. American Journal on Mental Retardation – Consensus Guidelines (May 2000) • This group published a consensus document that advocated for utilizing the following therapeutic interventions when treating an IDD population: • Applied behavioral techniques. • Cognitive behavioral techniques. • Behavior therapy. • Cognitive therapy. • Functional assessment. • Identification of antecedents and consequences of undesirable behaviors. • Environmental modifications to change, or interrupt, undesirable behaviors. • Reinforcement of desirable behaviors. • Uses basic tenets of operant and classical conditioning. • Retrieved from http://www.mhid.org/uploads/assets/16/EAMHID_Practice_Guideline_Assessment_and_Diagnosis_of_Mental_Disorders_in_People_with_IDD_Deb_et_al.__2001.pdf

18. Commonalities that Should Occur in all Therapies • Regardless of theoretical orientation, all treatment should begin with a comprehensive assessment (symptoms; functional impairment; history; ethnic and cultural background; cognitive impairment; learning disabilities; suicide risk; and homicidal ideation). • The therapeutic relationship, or working alliance, is also very important to the change process and should be evident in all theoretical orientations. • The lower the cognitive functioning of the individual, the more behaviorally oriented the intervention should be.

19. Behavioral Treatment for Depression • Behavior modification is the method of changing the way a person reacts either physically or mentally to a given stimulus. • By using this technique, undesirable behavior can be exchanged with more appropriate behaviors that can be substituted into the behavioral repertoire of the individual. • Behavior modification techniques (operant conditioning) include: • Thorndike Principle. • Behaviors followed by a satisfying consequence are repeated. • Shaping. • Reinforcement for approximations of the desired behavior. • Generalization of these new skills is likely the next step in treatment. • Contingency management. • Reinforcement of desired behavior. • Given rewards, such as verbal praise, for behavior that is inconsistent with depression. Retrieved from http://operationmeditation.com/discover/8-useful-behavior-modification-techniques-for-adults/

20. Behavioral Treatment for Depression • Example of Behavioral Therapy in the treatment of depression • Behavior Therapy postulates that depression can result from a stressor which disrupts normal behavior patterns causing a low rate of response contingent positive reinforcement. The rate of reinforcement is functionally related to the availability of reinforcing events, personal skills to act on the environment, or the impact of certain types of events. • If an individual cannot reverse the negative balance of reinforcement, a heightened state of self-awareness will follow that can lead to self-criticism and behavioral withdrawal. • The resulting behavioral therapy involves helping patients increase the frequency and quality of pleasant activities. • It has been found that depressed people have low rates of pleasant activities and obtained pleasure. • Research suggests that depressed individuals experience moodiness in response to both pleasant and aversive activities (as compared to the general population). • It is hypothesized that depressed individuals lack social skills, at least during the depressed phase, and this negative view contributes to the depression.

21. Behavioral Treatment for Depression • Treatment consists of: • Psychoeducation • Introducing techniques and strategies to cope with the problems that are assumed to be related to the depressive episode • Improving social skills • Addressing depressogenic thinking • Increasing pleasant activities • Relaxation training • Reinforcement at various success points • Education regarding basic communication, negotiation, and conflict-resolution skills • All of the above techniques are modified, as needed, in order to “meet” the individual at the emotional and cognitive level that was noted during the initial (comprehensive) assessment • Antonuccio, D.O. (1998). The coping with depression course: A behavioral treatment for depression. The Clinical Psychologist, 51 (3), 3-5

22. Behavioral Techniques Useful When Treating Depression Techniques for treating depression include: • Mood logs. • Self-statements. • Social skills training. • Frequent reinforcement for desirable behaviors. • Differential reinforcement of other behavior. • Positive reinforcement when the person has not made the typical (or undesired response).

23. Modified Daily Mood Log

24. Behavioral Treatments of Anxiety Disorders • In general, anxiety disorders are best treated with a combination of medication and behavioral therapy. • Behavioral techniques shown to be effective in the treatment of anxiety disorders: • Exposure-based behavioral therapy is the treatment of choice, and has been used for many years to treat anxiety, specific phobias, and response to trauma. • Techniques include: • Collaboratively developing an hierarchy that outlines the least to most fearful situations. Retrieved from http://www.nimh.nih.gov/health/publications/anxiety-disorders/index.shtml#pub7

25. Behavioral Treatments of Anxiety Disorders Techniques continued • Collaboratively developing an exposure plan, clearly stating how the stimuli will be presented. • Depending on the level of impairment, exposure may occur in-vivo, by showing a picture of the fear-inducing scenario or object, or other less threatening methods. • At this same time, a competing response is introduced and practiced during therapy sessions with the person. • This response is one that is incompatible with the anxiety response. • Relaxation • Evoking relaxing or soothing images. • The entire process of exposure and response prevention is called systematic desensitization. • This technique would be quite amendable to people of differing cognitive abilities. • Retrieved from http://www.nimh.nih.gov/health/publications/anxiety-disorders/index.shtml#pub7

26. Behavioral Treatment for Obsessive Compulsive Disorder • As is true with other anxiety disorders, OCD is often best treated with a combination of medication and behavioral therapy. • People with obsessive-compulsive disorder (OCD) have persistent, upsetting thoughts (obsessions) and use rituals (compulsions) to control the anxiety these thoughts produce. • Most of the time, the rituals end up controlling daily routines and significant amounts of time are spent engaging in ritualistic behaviors. Retrieved from http://www.nimh.nih.gov/health/publications/anxiety-disorders/index.shtml#pub7

27. Behavioral Treatment for Obsessive Compulsive Disorder • Therapeutic techniques would also be similar to other anxiety disorders, and include: • Exposure and response prevention. • Most types of exposure therapy. • Introducing competing responses. • All of these techniques would be amendable to people with cognitive limitations. Retrieved from http://www.nimh.nih.gov/health/publications/anxiety-disorders/index.shtml#pub7

28. The Use of CBT with the IDD Population • There are some indications that the use of cognitive-behavioral approaches for people with intellectual disabilities is becoming more widely accepted. • Lindsay (1999) showed that although some procedures may need to be adapted and simplified, people with intellectual disabilities and a variety of behavioral health problems can benefit from interventions that retain all the key elements of cognitive behavioral therapy. • Retrieved from http://nrl.northumbria.ac.uk/1124/1/CBT%20for%20People%20with%20Intellectual%20Disabilities.pdf

29. The Use of CBT with the IDD Population • Several studies have shown that people with intellectual disabilities (ID) have suitable skills to actively participate in cognitive behavioral therapy (CBT). • Case studies have reported the successful use of CBT techniques (with adaptations) when treating people with ID. • Modified CBT may be a feasible and effective approach for the treatment of depression, anxiety and other mood disorders in people with cognitive or other limitations. • Retrieved from dhs.sd.gov/ddc/documents/CognitiveBehaviorTherapy.pdf

30. The Use of CBT with the IDD Population • To date, two studies have reported successful group-based manualized cognitive behavioral treatment programs for depression in people with mild ID. • Currently, there is not a widely accepted manualized program for anxiety or depression for people impacted by an intellectual impairment. • Most researchers (e.g., Hatton, 2002) conclude that CBT-based treatments, appropriately modified, may be a feasible intervention option for people impacted by an intellectual disability. • Retrieved from dhs.sd.gov/ddc/documents/CognitiveBehaviorTherapy.pdf

31. The Use of CBT with the IDD Population • Current research teams are providing empirical support, published in a multitude of journals, noting that practitioners are beginning to offer CBT interventions routinely to people with intellectual disabilities who are also experiencing emotional problems. • While the evidence base is still limited, researchers continue to offer meaningful contributions to the literature base regarding treatment of this population. • For most individuals this includes a modified version of CBT. • Retrieved from dhs.sd.gov/ddc/documents/CognitiveBehaviorTherapy.pdf

32. The Use of CBT with the IDD Population • Behaviors that have the most robust support and response to CBT interventions include: • Self-management approaches. • Emotional labelling. • Recognition of the mediating role of cognitions. • Understanding the mediating role of cognitions. • Retrieved from dhs.sd.gov/ddc/documents/CognitiveBehaviorTherapy.pdf

33. The Use of CBT with the IDD Population • Willner (2005) found CBT interventions utilizing cognitive-skills training show promising results. • These include: • Self-management. • Self-monitoring. • Self instruction and training. • Retrieved from http://nrl.northumbria.ac.uk/1124/1/CBT%20for%20People%20with%20Intellectual%20Disabilities.pdf

34. Borderline Personality Disorder • Marcia Linehan is the primary authority in treating individuals diagnosed with borderline personality disorder. • Linehan’s intervention, dialectical behavior therapy (DBT), is a type of therapy that balances therapeutic validation and acceptance of the person. • (DBT) is closely aligned with cognitive and behavioral change strategies. • Lew, M., Matta, C., Tripp-Tebo, C., & Watts, D. (2006). Dialectical Behavioral Therapy with Individuals with Intellectual Disabilities 9(1), 1 – 13.

35. Borderline Personality Disorder • The emphasis of the DBT model is on teaching the individual to: • Modulate extreme emotions and reduce negative behaviors that result from those emotions. • Trust his or her own emotions, thoughts and behaviors. • These goals are accomplished through multiple treatment modalities (i.e., individual therapy, skills training, coaching and environmental interventions). • Lew, M., Matta, C., Tripp-Tebo, C., & Watts, D. (2006). Dialectical Behavioral Therapy with Individuals with Intellectual Disabilities 9(1), 1 – 13.

36. Borderline Personality Disorder • DBT can be modified in the following ways when working with an IDD population: • Reduce the use of metaphors and acronyms that are peppered throughout the manual. • Allow more time for problem solving and skill acquisition. • Accept that people with borderline personality disorder and IDD are extremely challenging, even to seasoned clinicians. • Lew, M., Matta, C., Tripp-Tebo, C., & Watts, D. (2006). Dialectical Behavioral Therapy with Individuals with Intellectual Disabilities 9(1), 1 – 13.

37. Borderline Personality Disorder • Multiple repetitions may be necessary to ensure understanding of lessons. • Readiness to participate in group sessions should be carefully assessed by the interdisciplinary team. • Participants may show initial, and sometimes protracted, regression prior to demonstrating treatment progress. • It is hypothesized that due to the complexity of the DBT program, some of the dually diagnosed participants took longer to learn the program, internalize the coping and self-management skills, and to become their own coach. • The researchers concluded DBT has significant potential to meet the behavioral health needs of people impacted with an IDD. • Lew, M., Matta, C., Tripp-Tebo, C., & Watts, D. (2006). Dialectical Behavioral Therapy with Individuals with Intellectual Disabilities 9(1), 1 – 13.

38. AACAP Work Group Commentary (1999) • Some clinicians target symptom suppression without regard for habilitative functioning. • Informed consent is often overlooked. • Medication often is not integrated as part of comprehensive treatment plans. • Medications often don’t match diagnosis. • Polypharmacy is overused. • There is often no active monitoring for side effects.

39. Outcomes • Patients served — 207. • Served inpatient — 184. • Served outpatient — 60. • Outpatient only — 23. • Inpatient only — 123. • Both inpatient and outpatient — 37.

40. Outcomes • Male - 56% • Female - 44% • Mean age at admission - 15 • At admission 50% state custody

41. Diagnosis • MR - 75% • Autism, PDD, LD, or met federal definition of DD - 25% • Autism or a PDD - 14% • Mood disorder - 35% • Anxiety disorder with PTSD - 25% • ADHD - 23% • Thought disorder- 4%

43. Outcomes

44. Juvenile Justice Involvement in DNP Youth

45. Mental Health Treatment can Reduce Arrest Rates in this Population • Post treatment 90% of these youth had either no jail time or jail time less than 30 days.

46. Lessons Learned • These youth are at risk for substance abuse and dependence. They need specialized services. • These youth are at risk of entering the juvenile justice system and adult corrections. • These youth are institutionalized as adults. • Failure to meet the needs of these youth is the most costly mistake that policymakers at both the state and federal level make.

47. This Presentation may present links to other Internet web sites for the convenience of users in locating information and services that may be of interest. These sites are maintained by organizations over which PerformCare exercises no control, and PerformCare expressly disclaims any responsibility for the content, the accuracy of the information and/or quality of products or services provided by or advertised on these third-party sites. PerformCare does not control, endorse, promote, or have any affiliation with any other web site unless expressly stated herein.