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Changes in the Rate of Problem Behavior Associated With the Discontinuation of the Antipsychotic Medication Quetiapine Maria G. Valdovinos, Ph.D., BCBA, 1 Nicholas P. Ellringer 1 & Michelle L. Alexander 1 1
D epartm ent of Psych ology, D rake University, D es M oines, IA
Using analogue functional analysis, we monitored changes in the rates of aggression and self-injury in a 50-year-old female diagnosed with severe intellectual disability and mood disorder. Functional analyses were conducted while the individual was treated with quetiapine (Seroquel) and citalopram (Celexa) and after the quetiapine was discontinued. Discontinuation of quetiapine resulted in differential responding patterns for aggression and self-injury. This case study provides support for functional assessment of problem behaviors during medication changes to determine if psychotropic medications are associated with subsequent changes in behavior. Keywords: aggression, antidepressant, antipsychotic, behavioral analysis, citalopram, developmental disability, intellectual disability, mental retardation, psychiatric disorder, quetiapine, SIB n 1994, Schaal and Hackenberg 7 called for a functional approach to the evaluation of the efficacy of psychotropic m edication for the treatment of problem behavior in individuals with developm ental disabilities. Since that tim e, research has been conducted evaluating the potentially differential effects that psychotropic medications have on the problem behavior of individuals with developm ental disability. For exam ple, using functional analysis methodology, Zarcone et al. 10 found that while risperidone was effective in decreasing rates of problem behavior in those with developm ental disability, it differentially reduced rates of problem behavior across conditions of a functional analysis for som e individuals and not others. Dicesare et al. 4 evaluated the effects that m ethylphenidate had on disruptive behaviors of a m ale diagnosed with attention-deficit hyperactivity disorder and moderate intellectual disability. They found that methylphenidate served to abolish the reinforcing effectiveness of attention within an analogue functional analysis. Analogue functional analysis is a type of assessm ent conducted to determine the function of behaviors of interest. Functional analysis involves the presentation of various conditions in which there is system atic manipulation and control of variables intended to mirror natural contingencies. For exam ple, if caregivers report that problem behaviors seem to occur m ore often when the individual is asked to do som ething, this
hypothesis can be assessed responses when the individual is asked to com ply with simple, everyday tasks. If problem behaviors occur during this condition, then the hypothesis is given support. 5 This type of assessm ent is advantageous because environm ental modifications can be made in which contingencies, that were systematically dem onstrated to be maintaining problem behavior, can be arranged for alternative, adaptive behavior instead. Evaluating potential changes in function of problem behavior following m edication changes is of vital im portance for optim al treatm ent. Often, when there are changes in m edication regimens, subsequent changes in behavioral programming are absent; however, if m edication alters problem behavior function (via changes in motivating operations, setting events, or some other mechanism), interventions to treat problem behavior should be modified accordingly. The purpose of this study was to determine if there were any changes in problem behavior associated with discontinuation of quetiapine for an individual diagnosed with severe intellectual disability using functional analysis methodology.
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M ETHOD Ms. A was a 50-year-old Caucasian woman diagnosed with severe intellectual disability (etiology unknown) with severe-profound deficits in adaptive functioning. She was diagnosed with a m ood disorder. In addition, she had chronic
2 dermatitis, and had an orthopedic disability requiring her to wear an ankle-foot orthosis for am bulation. Staff reported that she slept well (on average, 10 hours a night). At the beginning of the study, Ms. A was treated with 40mg of citalopram (Celexa), an antidepressant, and 75mg of quetiapine (Seroquel), an atypical antipsychotic, for her mood disorder. Quetiapine was prescribed to treat increased agitation (yelling, screaming), aggression, selfinjurious behavior (SIB ), and decreased participation in activities due to diminished pleasure. Quetiapine was then discontinued when staff reported an increase in presenting symptoms despite the low dose prescribed. All sessions were conducted in a recreation room in Ms. A’s home. This room contained two couches, a rocking recliner, a treadmill, and keyboard. Response Definition, Measurem ent, Interobserver Agreem ent Prior to meeting with Ms. A, we conducted an interview to determ ine the topographies and hypothesized functions of problem behavior and to identify preferred reinforcers. 6 Target problem behaviors identified for Ms. A were aggression, SIB, and food stealing. For the purposes of this study, we provided consequences for aggression and SIB. Aggression was defined as any tim e she, with an open or closed hand, forcefully m ade contact with any body part of another individual. SIB was defined as scratching her hand, biting her hand, and hitting herself with an open hand. It was reported that any food was reinforcing for Ms. A and that she often would engage in aggression in the kitchen to gain access to food. All sessions were videotaped and problem behaviors were scored by collecting the frequency of problem behaviors per 10-second intervals using a paper-and-pencil system . Interobserver agreem ent was calculated by dividing the num ber of agreements (occurrence plus nonoccurrence) by the number of agreem ents plus disagreem ents and multiplying by 100% . Agreem ent was obtained for 47.5% of all sessions. Mean agreement scores for aggression were 99.5% (range, 87% to 100% ) and for SIB were 95% (range, 81.7% to 100% ). Design and Procedure Analogue functional analysis was conducted using a m ultielem ent design within an AB design. 5 Ten sessions were conducted when M s. A was Mental Health Aspects of Developmental Disabilities
prescribed quetiapine and an additional 10 sessions were conducted at three different times after the medication was discontinued (5 days, 3 and 4 weeks after discontinuation). Each condition was 5 minutes long with a 1-minute break between conditions. Consequences were provided for aggression and self-injury only. Conditions included attention, control, demand, ignore, and edible. During the attention condition, verbal attention was withheld from Ms. A unless she engaged in target behaviors upon which the researcher would deliver attention in the form of a statement (e.g., “Stop that, you’re going to hurt yourself.”). During the control condition, attention and preferred activities (e.g., demo songs playing on keyboard, magazines, beads for a necklace) were made available to Ms. A. During the demand condition, Ms. A was presented with various demands (e.g., fold your shirt) and was allowed to escape from a demand for 15 seconds contingent on target problem behavior. In the ignore condition, attention was withheld and no demands were made. Finally, during the edible condition, access to food (i.e., grapes and cheese) was made available contingent on aggression or SIB.
R ESULTS Results of the functional analysis are shown in Figure 1. The top panel presents analogue functional analysis data for aggression and the bottom panel presents data for SIB. W hen M s. A was treated with quetiapine, overall rates of aggression (0.52 rates per minute [rpm ]) were higher than when quetiapine was discontinued (0.03 rpm ). During the edible condition while treated with quetiapine, aggression occurred at a rate of 2.6 instances per m inute and 0.06 instances per minute when quetiapine was discontinued. W hile treated with quetiapine, rates of SIB averaged 0.58 instances per m inute across all conditions (with the exception of the attention, there was an increasing response trend during this condition). Once quetiapine was discontinued, rates of overall SIB increased (1.57 rpm). W ith regard to function of SIB, responding was undifferentiated while treated with quetiapine with the highest rates of SIB occurring during the edible (0.9 rpm ), ignore (0.5 rpm ), and control (1.1 rpm) conditions. Once quetiapine was discontinued, rates of SIB increased in all conditions (dem and 0.2 rpm to 1.73 rpm; edible increased to 2.37 rpm; ignore increased to 1.23 rpm ; control increased to 1.8 rpm). Rates of SIB
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F IGURE 1. Aggressions per m inute during analogue functional analysis sessions conducted when treated with quetiapine and citalopram and when treated w ith citalopram alone (top panel). SIB per minute during analogue functional analysis sessions conducted when on quetiapine and citalopram and when on citalopram alone (bottom panel).
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4 in the attention condition, however, remained relatively constant across the quetiapine and no quetiapine conditions (0.2 rpm and 0.7 rpm respectively).
D ISCUSSION As previously stated, the purpose of this study was to m onitor behavior function during the discontinuation of quetiapine, an atypical antipsychotic prescribed in this case to treat agitation and problem behavior associated with her m ood disorder. For this study, we found that the overall rates of aggression were higher when treated with quetiapine and rates of SIB increased across all conditions when quetiapine was discontinued. This finding is interesting in light of research that suggests quetiapine has little effect in treating problem behaviors in those with autism or other developmental disabilities. 1 Our results suggest a possible change in function of aggression (loss of an edible function) and a decrease in the rate of aggression as a result of the discontinuation of quetiapine. The changes in aggression and SIB taken together are conflicting. It is possible that Ms. A experienced an increase in appetite as a result of quetiapine which served as a motivating operation to establish edibles as a reinforcer, but that function was not apparent for SIB.9 Another explanation for the differences observed between aggression and SIB m ay be that SIB was unaffected by quetiapine as the rate of SIB appeared to be increasing across sessions during the quetiapine condition. The trend m ay have m erely been continuing once quetiapine was discontinued. Although SIB rates were higher after quetiapine was discontinued than in baseline, there was a downward trend across all conditions except the dem and condition, in which the SIB seem ed to increase. An explanation for this result may be that negatively reinforced behavior was affected m ore than other socially mediated functions while treated with quetiapine. This effect has been dem onstrated in the anim al literature with various antipsychotic m edications and in the hum an literature with individuals with developm ental disabilities using risperidone. 3,8 Unfortunately, we were not able to conduct a d d ition a l s es sio n s pr io r to q u e tiap ine discontinuation to determine differentiation of SIB responding, nor were we able to reinstate quetiapine to establish a reversal of function and rates of problem behavior as were seen in the initial sessions. Adm ittedly, the lack of reversal to
Mental Health Aspects of Developmental Disabilities
baseline and the absence of an assessm ent prior to initiation of quetiapine did not allow for an adequate evaluation of the effects of quetiapine on problem behavior; however, the focus of this study was on assessment and evaluating behavior function relative to medication administration. For this individual, the discontinuation of quetiapine decreased her agitation and aggressive behaviors but had no effect on her self-injury. These findings support a previous retrospective study that suggests quetiapine has a modest effect on the treatment of problem behavior in those with developmental disabilities.2 Finally, this study provides support for conducting assessments throughout psychotropic medication changes to determine if changes in dose or medication affect previously identified functions of problem behavior. R E FE RE N CE S 1.
Barnard L, Young AH, Pearson J, et al. A systematic review of the use of atypical antipsychotics in autism. J Psychopharmacol 2002;16:93-101.
2.
Corson AH, Barkenbus JE, Posey DJ, et al. A retrospective analysis of quetiapine in the treatment of pervasive developmental disorders. J Clin Psychiatry 2004;65:15311536.
3.
Crosland KA, Zarcone JR, Lindauer SE, et al. Use of functional analysis methodology in the evaluation of medication effects. J Autism Dev Disord 2003;33:271-279.
4.
Dicesare A, McAdam DB, Toner A, Varrell J. The effects of methylphenidate on a functional analysis of disruptive behavior: A replication and extension. J Appl Behav Anal 2005;38:125-128.
5.
Iwata BA, Dorsey MF, Slifer KJ, et al. Toward a functional analysis of self-injury. J App Behav Anal 1994;27:197-209. (Reprinted from Anal Intervent Dev Disabil 1982;2:3-20.)
6.
O’Neill RE, Horner RH, Albin RW, et al. Functional Assessment and Program Development for Problem Behavior. Pacific Grove, CA: Brooks/Cole Publishing, 1997.
7.
Schaal DW, Hackenberg T. Toward a functional analysis of drug treatment for behavior problems of people with developmental disabilities. Am J Ment Retard 1994;99:123140.
8.
Shannon HE, Hart JC, Bymaster FP, et al. Muscarinic receptor agonists, like dopamine receptor antagonist antipsychotics, inhibit conditioned avoidance response in rats. J Pharmacol Exp Ther 1999;290:901-907.
9.
Valdovinos MG, Kennedy CH. Behavior analytic conceptualization of psychotropic medication side effects. Behav Anal 2004;27:231-238.
10. Zarcone JR, Lindauer SE, Morse PS, et al. Effects of risperidone on destructive behavior of persons with developmental disabilities: III. Functional analysis. Am J Ment Retard 2004;109:310-321.
C O R RE SP O ND EN CE : Maria G. Valdovinos, Ph.D., BCBA, Drake University, Psychology Departm ent, 2507 University Avenue, Des Moines, IA 50312; em ail: m
[email protected].
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