For many individuals on the Autism spectrum, treatment is multi-pronged. For some individuals, psychotropic medications are used to improve behaviors and symptoms.
Board Certified Behavior Analysts (BCBA) provide life changing Applied Behavior Analysis (ABA) therapy that uses observation, data, and the power of positive reinforcement to help individuals who engage in challenging behaviors learn socially appropriate ones. BCBAs do not prescribe medications, but they often serve clients whose family and doctors make the decision to use medications as part of a treatment plan. What is the role of a BCBA on a care team for a client on psychotropic medications?
The truth is, when it comes to psychotropic medications, BCBAs have very little say over how it is prescribed. Many BCBAs disagree with the use of excessive medication. However, it simply is out of the BCBA’s scope of practice to argue against it. But what can a BCBA do? BCBAs have an ethical responsibility to provide the best possible care for a client, and make decisions based on what they believe that care to be.
While it is unethical to try and deny a client access to psychotropic medication, BCBAs can use data collection and monitoring to determine whether or not medication is having the desired outcome. BCBA’s have a keen eye for behavior and are uniquely talented at data collection. With the right data, BCBAs can argue for the discontinuation of a medication that is not working appropriately or is causing an increase in challenging behaviors.
If you visit another country, you should learn to speak some of the language. In that same sense, if you are a BCBA who works with a client who has been prescribed psychotropics, you should learn to speak the language of psychiatrists. In this blog post, inspired by a presentation by Tom Freeman, we will walk BCBAs through how they can navigate the world of psychotropic medications.
This article is designed to spark your curiosity – remember to continue your research using reliable, evidence-backed sources.
What are Psychotropic Medications?
One of the greatest modern marvels of science is our developing understanding of neurotransmitters. Neurotransmitters are your body’s medical messengers; they travel through tiny gaps called synapses to send messages to the brain, body, and glands. The human brain contains over 1 quadrillion synapses. Though scientists have currently identified seven neurotransmitters, the brain has 100s that have yet to be studied. We still have a lot to learn!
Psychotropic Medications work by altering or binding to neurotransmitters, which changes the way they travel through the body. Neurotransmitters can “excite” your neurons and encourage them to pass a message along, or they “inhibit” neurons by calming them down and decreasing the amount of messages sent. There are also “modulatory” neurotransmitters that make adjustments to how groups of neurons behave.
Some known drug/neurotransmitter links
- Dopamine (e.g. Antipsychotics [aka, FGAs, SGAs, AAPs, Antidepressants, ADHD meds)
- Serotonin (e.g., FGAs, AAPs, Antidepressants)
- Norepinephrine (SNRIs, MAOIs, TCAs, ADHD Meds)
- Acetylochine (All antipsychotics, some others)
- GABA (Anxiolytics, barbituates)
- Glutamate (Ketamine)
- Histamine (All antipsychotics, all antidepressants)
Five Types of Drug Effects
There are five main types of drug effects. It’s important to recognize and differentiate between these drug effects when BCBAs are monitoring symptoms and collecting data.
We call whatever the desired therapeutic impact is the “main effect.” This desired effect is the reason why the client has been placed on the medication to begin with. It’s very important to determine if the main effect is working, and measure it against other potential effects.
Any metabolic or physiological effects that are not defined as a desired effect are Side Effects. These effects can be benign or serious, so it’s important to keep an eye out for anything outside of the normal.
Aside from the Main Effect, there are Secondary Effects. While sometimes considered to be under the umbrella of “side effects,” Secondary Effects refers specifically to the behavioral impact of physiological side effects. For instance, a medication that makes someone lethargic might lead to a decrease in aggressive behaviors.
Toxic Effects are what happen when a person’s blood levels are too high and they experience a drug overdose. It’s extremely important to understand the correct dosages of medication, and understand how drugs interact with each other. As a member of a client’s care team, keeping them safe should be one of your chief concerns.
Finally, it’s always possible for someone to have an Allergic Reaction to a drug. Allergic reactions are usually characterized by things like rash or anaphylaxis. When an allergic reaction happens, it’s important to discontinue use of the drug immediately and talk to a doctor as soon as possible.
Understanding Dosage
Remember just a few paragraphs ago when we talked about Toxic Effects? Toxic effects pose a real threat to individuals who take Psychotropic Medications. For this reason, it is imperative that everyone on a client’s care team has a keen understanding of drug dosage.
The way drugs live in the body is measured on a “half-life” formula. These “half lives” are the unique estimations of the time it takes for one half of the drug to leave the body. For instance, if a drug has a 2 hour half life, after 2 hours, 50% of the drug remains in the body, after another 2 hours 25% of the original dose remains (1/2 of 50%), and so on and so forth until the drug has completely left the body.
It’s especially important to pay close attention to the dosage schedule of drugs with short half-lives. When a drug’s half-life is short, even just one missed dose can have a big clinical impact.
All BCBAs should learn to read and understand Common Dosage Abbreviations:
QD: (1x) Once per day
BiD: (2x) Two (different) times per day
TiD: (3x) Three times per day
QiD: (4x) Four times per day – be careful, this is awfully close to QD!
HS: Hour of sleep
PRN: As needed
Keep in mind that the route of administration has a direct impact on how quickly the drug is absorbed. Generally speaking, injections, rectum insertions, lung inhalations, and sublingual medications are the fastest.
Training Caregivers
As a BCBA you are often involved in training parents, caregivers, and staff members on clients’ daily routines. It’s important that all members of a client’s care team are trained to understand dosage and identify unfavorable side effects.
Furthermore, all caregivers should be trained to recognize some of the dangerous disorders that can arise as a serious adverse reaction to drugs. These disorders can lead to lifelong medical conditions. Prudence is necessary to determine what possible side effects are worth the risk, and education about these extreme outcomes is a necessary piece of the equation.
Listed below are links to resources that will help you understand the possible adverse effects of medication.
https://my.clevelandclinic.org/health/treatments/anticholinergic-drugs
EPS:
https://my.clevelandclinic.org/health/diseases/22815-parkinsonism
https://my.clevelandclinic.org/health/diseases/23954-akathisia
https://my.clevelandclinic.org/health/diseases/6125-tardive-dyskinesia
Resource for tracking EPS, the A.I.M.S. system: https://www.ohsu.edu/sites/default/files/2019-10/%28AIMS%29%20Abnormal%20Involuntary%20Movement%20Scale.pdf
Life threatening Reactions:
https://www.mayoclinic.org/diseases-conditions/serotonin-syndrome/symptoms-causes/syc-20354758
https://my.clevelandclinic.org/health/diseases/22703-neuroleptic-malignant-syndrome
The Role of a BCBA Regarding Psychotropic Medications
To meet the ethical standards set by the BACB, every BCBA should strive to understand psychotropic drugs to the best of their ability. Through attending CE Events, reading textbooks, and asking questions, the BCBA should learn to speak fluent psychologist. They should learn the language of medication class, side effects, toxic effects, and the different syndromes that can arise in response to medication. Of course, as is the case with any position in the medical field, learning cross-discipline collaboration skills is invaluable to the BCBA.
While BCBAs can’t change the way drugs are administered, they are liable to understand how drugs might affect behavior. BCBAs can create charts on the behaviors that drugs are being used to treat and collect data as they would on any other behavior. That way, they can determine how effective drugs are in increasing or decreasing certain behaviors. BCBAs should attend medication management meetings with the client’s physician whenever possible. If the BCBA cannot attend themselves, they should provide staff/family with behavior reports (in layman’s terms) to share data with the doctor.
Ultimately, it is the goal of BCBAs to help their clients become as independent as possible. While medication can be helpful for many, it is widely agreed that the best practice in terms of psychotropic medications is to take the best medication available at the lowest dosage necessary, for the shortest amount of time necessary. Wherever it is possible, discontinuation should be the goal. BCBAs believe that the greatest tool for changing behavior is positive reinforcement, not drugs.
About ABA-LLC
ABA-LLC is one of the largest suppliers of Behavior Support in the state of Kentucky. Since 2007, the agency has created innovative strategies to improve the lives of unique individuals. ABA-LLC works with around 190 contractors, each dedicated to building an inclusive culture that celebrates individuals of all abilities. No matter who you are, you can reach your goals at ABA-LLC.
ABA-LLC is set apart from its competitors by its uniquely person-centered approach. The agency strives to provide services from a place of deep love for the population it serves. Their work exemplifies the belief that every individual has a right to live a fulfilling and independent life integrated within their communities. There is no objective to change a person, but rather to give them the tools they need to succeed. B.F. Skinner summarizes this vision in his quote: “I’m not trying to change people. All I want is to change the world in which they live.” Learn more about us at https://aba-llc.com/