reducing psychotropic medications in an intensive residential treatment center

Psychotropic Medication Rates

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ORIGINAL PAPER

Reducing psychotropic medications in an intensive residential treatment center

Jonathan C. Huefner • Annette K. Griffith • Gail L. Smith • Dennis G. Vollmer • Laurel K. Leslie

J.C. Huefner • G.L. Smith

Boys Town National Research Institute for Child and Family Studies, Boys Town, NE 68010

e-mail: [email protected]

A.K. Griffith

Missouri Department of Mental Health, Kansas City, MO

D.G. Vollmer

Boys Town National Research Hospital, Omaha, NE

L.K. Leslie

Tufts Medical Center, Boston, MA


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Abstract

Medication rates in behaviorally disordered children and youth have greatly increased to

current high levels and are very controversial. This study examined changes in psychotropic

medication use, levels of behavioral disturbance, and use of personal restraint and seclusion in a

population of youth with serious behavioral disorders receiving medically directed cognitive-

behavioral treatment in an intensive residential setting. The hypothesis was that there would be

significant reductions in medication rates, without the unintended consequences of increased

rates of problem behavior or offsetting increases in the use of seclusion or personal restraint.

Results showed significant reductions in both the number of youth on medication and the

average number of psychotropic medications during the residential stay. There were also

significant reductions in behavioral disturbance, seclusions, and personal restraints. These results

demonstrate that psychotropic medication can be significantly reduced without increases in

problem behavior or the use of seclusions or personal restraints. We conclude that it is possible

to significantly reduce psychotropic medication rates to far more conservative levels within the

context of a clinically directed cognitive-behavioral treatment milieu.

Key words: psychotropic medication, residential treatment, aggression, personal restraint,

seclusion


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Introduction

Medication rates in behaviorally disordered children and youth are high and

controversial. The psychotropic medication rates of behaviorally disordered youth have greatly

increased since the early 90’s (Heflinger & Humphreys, 2008; LeFever, Arcona, & Antonuccio,

2003; Najjar et al., 2004), despite the fact that the evidence for the effectiveness of

pharmacotherapy in children and youth is limited. Research has shown that 68% to 79% of youth

entering residential treatment settings are on one or more medications (Connor, Ozbayrak,

Harrison, & Melloni, 1998; Griffith et al., 2009; Hussey & Guo, 2005), and up to 55% of

medicated youth have three or more psychotropic prescriptions (Griffith et al., 2010). Many

youth in out-of-home placements have severe emotional and behavioral impairments (Pottick,

Warner, & Yoder, 2005), so it follows that psychotropic medication will play a role in the

treatment of many of these children. The research supporting pharmacotherapy for emotionally

and behaviorally troubled youth has tended to focus on how specific psychotropic medications

can effectively reduce mental health and behavioral symptoms, especially for ADHD,

depression, and severe behavioral disorders (Schachter, Pham, King, Langford, & Moher, 2001;

Swanson et al., 2008; Van Bellinghen & De Troch, 2001; Vitiello et al., 2006). There is a gap,

however, between controlled efficacy research and current pharmacotherapeutic practice.

Many medications prescribed for children and adolescents are off label (i.e., not FDA

approved) and pose significant health risks, with little or no efficacy data to support their use

(Leo, 2006; Zito, Craig, & Wanderling, 1994). In fact, most of the recent increase in medications

has been in the use of newer drugs, in spite of limited efficacy and safety data for pediatric

populations (Brown, 2005; Najjar et al., 2004). Overall, it is clear that current pharmacotherapy

practice for children and youth reflects many medication classes being used for variety of

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disorders, and many diagnoses being treated with a variety of drug classes (Guevara, Lozano,

Wickizer, Mell, & Gephart, 2002; Pathak et al., 2004; Zito et al., 2008). For instance, significant

numbers of youth are prescribed antipsychotic medication to treat behavioral symptoms such as

aggression and have no clinical indication of psychosis (Pogge, Young, Insalaco, & Harvey,

2007; Rawal, Lyons, MacIntyre II, & Hunter, 2004). Potential problems increase with high rates

of polypharmacy (Fontanella, Bridge, & Campo, 2009; Kubiszyn, 2005; Vitiello, 2005), where

drug interactions pose their own unique problems (Duffy et al., 2005; Woolston, 1999). Careful

clinical evaluation and risk assessment for off-label prescriptions and polypharmacy (Foltz,

2006; Haw & Stubbs, 2007) should form the basis for tapering medications in clinical practice

(Spellman et al., 2010).

It is noteworthy that research to date indicates that high medication rates are associated

with both clinically indicated and non-clinical factors (Pavkov & Walrath, 2008). Examples of

clinically indicated factors include specific disorders, as well as a history of aggression, disabling

social adjustment, abuse or suicidal behavior (Dean, McDermott, & Marshall, 2006; Safer, Zito,

& dosReis, 2003). Examples of non-clinical factors associated with higher medication rates

include being male, Caucasian, a ward of the state, and private insurance (dosReis et al., 2005;

Martin, Van Hoof, Stubbe, Sherwin, & Scahill, 2003; Zito, Safer, Zuckerman, Gardner, &

Soeken, 2005). Admission to an inpatient setting also predicts medication use; studies examining

medication rates in inpatient psychiatric hospital settings typically show that the number of youth

on medication increases from a range of 52% to 64% at admission to a range of 79% to 91% at

discharge (Lekhwani, Nair, Nikhinson, & Ambrosini, 2004; Pathak et al., 2004; Singh, Landrum,

Donatelli, & Hampton, 1994; Warner, Fontanella, & Pottick, 2007). Of particular relevance to

this study is the finding that the number of prior inpatient psychiatric hospitalizations is

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https://www.researchgate.net/publication/12741399_Combined_Pharmacotherapy_Pitfalls_of_Treatment?el=1_x_8&enrichId=rgreq-30cbe053-5d37-4c4b-a963-440642e6e7bc&enrichSource=Y292ZXJQYWdlOzI1NzU3ODYwNDtBUzoxNzEwNzM2NTYwNzQyNDFAMTQxNzc5ODU0NjY5NA==

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positively correlated with the total number of medication trials in youth in inpatient settings

(Lekhwani et al., 2004; Zakriski, Wheeler, Burda, & Shields, 2005).

There are only a few studies that have examined psychotropic medication rates in

intensive residential treatment programs (see the Method’s Setting section for what this means

specifically in the case of this research). Research conducted in this setting has found that,

similar to inpatient hospitalization, residential programs designed to treat children and

adolescents with serious emotional and behavioral disturbance have high medication rates (76%

to 89%) and many youth enter these programs on two or more medications (Connor et al., 1998;

Connor, Ozbayrak, Kusiak, Caponi, & Melloni, 1997; Hussey & Guo, 2005). There is also

significant use of off-label medication use in these settings (Rawal et al., 2004). Youth in these

settings who are on medication also had significantly longer lengths of stay compared to youth

not on any medication (Hussey & Guo, 2005; Lekhwani et al., 2004).

Studies have shown that behavioral interventions have been shown to be effective in

reducing medication rates within intensive residential treatment settings (Connor & McLaughlin,

2005; Foxx, 1998). Several researchers have argued that because of their comparable efficacy,

behavioral interventions should be tried first in order to protect youth from pharmacological risks

(LeFever et al., 2003; Timimi & Maitra, 2006). Others have argued that psychotropic

medications should be tapered off or discontinued for patients who are either not responding to

pharmacotherapy or whose symptoms have been in remission for 6 or more months

(Pappadopulos et al., 2003). Even with reductions in medication rates, however, most youth on

medication at the time of admission to residential treatment programs remained on some type of

psychotropic medication during care and at departure, indicating that pharmacotherapy continued

to play an important role in their treatment (Connor & McLaughlin, 2005; Pappadopulos et al.,


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2006). However, the combination of intensive behavioral interventions has been suggested to

permit lower numbers and doses of medications (Pelham et al., 2005).

This study examined medication rates for youth with serious emotional and behavioral

disorders who entered an intensive residential treatment center (IRTC) with a strong behavioral

component to its treatment program. The IRTC setting is a locked, 24-hour residential treatment

program for youth ages 7 to 18 with psychiatric disorders, specifically designed to offer care for

more seriously troubled youth who require treatment, supervision, and therapy in a safe

environment, but do not require inpatient psychiatric care. This program uses a medically

directed psycho-educational treatment model with a strong medication management focus that

emphasizes the minimum optimal medication level for each youth based on daily behavioral

reports (Spellman et al., 2010).

The specific hypothesis used here was that there would be significant reductions in

medication rates for youth in the program, without the unintended consequences of increased

rates of behavioral disturbance or compensatory increases in the use of personal restraint.

Behavioral problems are a primary risk factor for entering residential care (Boxer, 2007; Trout,

Hagaman, Casey, Reid, & Epstein, 2008), and are significantly associated with the use of

restraint (Dean, Duke, George, & Scott, 2007; Sukhodolsky, Cardona, & Martin, 2005) and

pharmacotherapy (Connor et al., 1997). We postulated that, in a setting with a strong behavioral

component, if the medications youth were on at the time of admission were in fact appropriate to

youth’s treatment needs and the youth were unresponsive to behavioral interventions, then taking

them off those medications should be followed by unwanted emotional and behavioral problems.

If, however, medication reductions are not followed by worsening emotional and behavioral

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problems, then the argument can be made that the medications that were removed were not

clinically appropriate.

Method

Subjects

This study examined 228 youth consecutively admitted between 2005 and 2007 to an

IRTC in the Midwest who spent at least 30 days in the program. We specified that, for analytic

purposes, youth needed to be enrolled in the program a minimum of 30 days as the dependent

measures were based on the first two weeks and last two weeks of behavior, and this roughly

corresponds to 30 days. The average age at the time of admission was 14.0 years old (SD = 2.5)

and the length of stay was 4.5 months (SD = 3.4). Sex, race, state ward custody status, referral

source, and living setting prior to admission are shown in Table 1. Referral source and living

setting prior to admission were noteworthy, where almost two-thirds of youth were mental health

referrals with most coming mostly from inpatient or juvenile justice settings.

The IRTC program receives funding primarily through Medicaid, however also receives

funding through a variety of other sources such as private pay, private insurance, and contracts

with juvenile justice departments. All youth in the program have at least one DSM diagnosis.

The diagnosis on admission is based on standard diagnostic evaluation by the program’s staff

psychiatrist that incorporates a clinical interview as well as past records and contacts with

collaterals. The most common admission classes of primary diagnoses were behavioral disorders

(61%), followed by mood disorders (29%), anxiety disorders (3%), adjustment, impulse, and

psychotic disorders (all at 2%), and substance abuse (1%).


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Setting

The IRTC is a locked, 24-hour residential treatment program for youth ages 7 to 18 with

psychiatric disorders. It is a short to mid-term residential program specifically designed to offer

medically directed care for more seriously troubled youth who require supervision, safety, and

therapy but do not require inpatient psychiatric care. The program provides round-the-clock

supervision, locked/secure facilities, and numerous other safety and program features. For many

of these high-risk youth, placements in traditional treatment programs have repeatedly failed and

reunification with the family holds little promise without stabilizing intervention.

The IRTC consists of four secured units located within a research hospital setting that has

the capacity to provide treatment for 47 youth. Most youth are admitted to this program

following residence in a highly restrictive setting (e.g., inpatient hospitalization, juvenile justice

detention). These youth manifest high rates of aggression (46.6 daily acts per 100 youth). The

IRTC may utilize interventions such as personal restraints or seclusions in order to safely

manage extreme behaviors that present imminent danger to self or others. All personal restraints

require a physician’s order by a staff psychiatrist. Staff are trained in Non-violent Crisis

Intervention (NCI), which is a nationally certified personal restraint model. The program also

utilized a staff intensive process for prone restraints. All personal restraints are under the direct

observation of a registered nurse who is present to ensure that the personal restraint models are

safely applied and the child is not under physiological stress. The program adheres to all

guidelines and regulations set forth by the Center for Medicaid Services (CMS) regarding the

utilizations of personal restraints and seclusions.

In addition to the medically directed care, the IRTC uses a psycho-educational treatment

model (PEM; Daly et al., 1998), which is a psycho-social cognitive behavioral approach to


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treatment. The PEM serves as an adjunct to the medical model traditionally found in psychiatric

settings. The psycho-social aspect of the PEM is reflected in the model’s focus on staff/patient

interactions. By design the PEM also enhances the utilization of a most available, yet frequently

overlooked treatment resource, the treatment technician. Early research indicated that patients

spend over 70% of their awake time each day with direct care staff in psychiatric treatment

settings (Criste, 1989). The PEM promotes treatment from a teaching perspective and allows

each staff person to be a treatment agent. It should be noted that youth in this program receive

schooling within a special education classroom in the unit, and classroom teachers are also seen

as treatment agents.

The Direct Care staff, who interact continuously with youth in the program, have as their

primary role to teach appropriate social, academic, and independent living skills to each youth.

This occurs at all times including school, mealtime, and playtime. The IRTC maintains a 4:1 day

and evening, and a 6:1 overnight youth to staff ratio.

Measures

Psychotropic Medication. All medication data used in this study were collected from the

IRTC’s clinical database which included patient information relating to specific medications,

dosage, frequency, and start and end dates. This included information on medications taken by a

youth at the time of entry into the program as well as medication changes made during treatment.

Two measures were used: 1) on a psychotropic medication (yes/no), and 2) number of

psychotropic medications (range 0 to 8).

Critical Events. Emotional and Behavioral problem behavior and restraint data come

from direct observation of behaviors gathered in a clinical management tool called the Treatment

Progress Checklist (TPC). The TPC is a modified version of Chamberlain’s Parent Daily Report


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(Chamberlain et al., 2006; Chamberlain & Reid, 1987). The TPC report logs all significant

events (e.g., property damage, self-destructive behavior, physical assault, etc.) that occur at the

setting during each of the three shifts each day. Each clinically-significant recorded incident

includes a descriptive narrative of the behavior or event and the selection of at least one of 46

codes. Each code has been behaviorally defined so charting is consistent across staff entries.

Some incidents may include more than one code. Direct-care staff record these events in a TPC

(paper form) at the end of each shift for each child (one form per day, divided into three sections,

one section for each shift). The narrative description of each incident correlates to one or more

pre-defined behavioral codes. Staff are trained in the use of the TPC during a two-week pre-

service course. Following the two week pre-service course, the new staff will job shadow a more

experienced staff member and complete a mock-TPC at the end of every shift. During this week

the mock-TPC is compared to the TPC completed by the more experienced staff member as

training in the accurate and proper implementation of this instrument. TPC data is entered into

the database by the over-night direct care staff at the end of every day.

This study used the five behavioral clusters from the TPC: Aggression, Covert,

Hyperactivity, Internalizing, and Oppositional (Larzelere, Chmelka, Schmidt, & Jones, 2002).

Each of the behavioral clusters is based on 5 or 6 observed behaviors. For example, the six TPC

items for the Aggression subscale are Physical Aggression Toward Objects, Physical Assault of

an Adult, Physical Assault of a Peer or Sibling, Physical Assault Attempt of Another Person,

Property Damage, Threatening (verbal or symbolic). Each of these items is clearly defined in

behavioral terms. For example, Physical Assault of a Peer or Sibling is defined as: “Youth

assaults a peer or sibling. Injury may or may not have resulted, but intentional aggressive

physical contact occurred (e.g., biting, choking, kicking, punching, scratching, pushing, jumping


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on, spitting at, throwing objects at).” This level of detail holds for all the items for each of the

subscales. The internal consistency for the subscales range from .58 to .89 (Larzelere et al.,

2002). Because of the importance of the issue for this population, an additional sixth scale was

included based on three items related to suicidal ideation and self-destructive behavior. Personal

restraint and seclusion were both measured by a single TPC item. Therapeutic hold/Physical

management is defined as: “A staff member or other adult therapeutically holds a youth to keep

him/her from harming self or others.” Restraints are only done manually and only by staff that

have received training on its proper use. This IRTC does not permit any form of mechanical

restraint.

TPC items record the number of times a specific behavior is expressed during a day, each

behavior potentially occurring a number of times within a day. A youth’s score for a given

behavior subscale for a two week period is the sum of all applicable behaviors for that scale over

a two week period. The potential range for daily incident data begins at 0 (no negative behavior

occurred), with no real upper limit. The descriptive data for the critical events in this study are

shown in Table 2.

Analysis

Repeated measures MANOVAs were used for significance testing. The first used a pre-

post (admission versus discharge) design with two dependent measures: 1) the number of youth

on psychotropic medication and 2) the average number of psychotropic medication.

Additionally, subject sex was used to account for known differences between males and females

for medication rates (Safer et al., 2003; Zito et al., 2008). The purpose for this analysis was to

verify that overall, significant changes in psychotropic medication use were occurring during the

residential treatment episode.

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Based on the finding that there were significant changes in the use of psychotropic

medication over time (see Results), a variable was created to capture four types of medication

status for youth in the study (hereafter Group): medications reduced during stay – Medication

Reduction (n = 135, 59%); on medication at admission, no change during stay – Medication

Maintenance (n = 34, 15%); not on medication at any time – No-medication (n = 30, 13%); and

medications increased during stay – Medication Increase (n = 29, 13%). Medication reduction

was defined as being on at least one fewer medications at the time of departure compared to the

time of admission (e.g., youth enters on three medications and departs on two medications – not

necessarily the same medications). Similarly, medication increase was defined as being on at

least one more medication at the time of departure than at the time of admission (e.g., youth

enters on no medication and departs on one medication). Finally, medication maintenance was

defined as youth departing on the same number of medications as at the time of admission

(again, not necessarily the same mediations). The average number of medications at the time of

admission for these groups was 3.4 for the Medication Reduction group, 2.3 for the Medication

Maintenance, .8 for the Medication Increased group, and 0 for the No-medication group.

The second MANOVA was a 2 by 2 (Group by Sex) repeated measures design, with

eight dependent measures: the behavioral clusters (Aggression, Covert, Hyperactivity,

Internalizing, Oppositional, and Suicidal), and intervention events (seclusion and restraint) for

the first two weeks in the program were compared with those same events for the last two weeks

in the program,

As is typical with incident data, behavioral clusters and intervention event rates were

highly skewed (all positively). A reciprocal transformation was used in order to minimize the

impact of non-normality.


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Results

This study examined the utilization of psychotropic medications, rates of behavioral

disturbance, and the use of personal restraint over time in an intensive residential program.

Overall, 79.4% of the children were on medication at the time of admission, with an average

number of 2.5 medications. The range for the number of medications at the time of admission

was from 0 to 8. A 2x2 (Time by Sex) MANOVA showed that there were overall significant

effects for Time (pre/post change) and for Sex; F (2, 225) = 54.6, p < .001 and F (2, 225) = 3.8, p

< .05 respectively. Specifically, first there was a 15.5% reduction in the number of youth on

medications from admission to discharge, going from 79.4% at admission to 67.1% at discharge,

F (1, 227) = 13.3, p < .001. Second, there was a 46.0% reduction in the average number of

medications per youth, going from an average of 2.5 (SD = 1.8) medications at admission to 1.3

(SD = 1.2) medications at discharge, F (1, 227) = 102.2, p < .001. For the youth on medication at

the time of admission, 74.6% experienced a reduction of dropping one or more psychotropic

medication, with some being taking off psychotropic medications altogether. The univariate

analyses for Sex, however, did not yield a significant result for either the number of youth on

medications nor for the average number of medications F (1, 226) = 3.1, p = .08 and F (1, 226) =

.01, p = .91 respectively.

A 2x2x4 (Time by Sex by Group) Repeated measures MANOVA was used to examine

the relationship between changes in medication and impact on the six emotional and behavioral

disturbance indices, and the use of seclusion and personal restraint. There were overall

significant differences for each of the main effects: Time, F (8, 213) = 4.9, p < .001; Sex, F (8,

213) = 9.8, p < .001; and Group, F (24, 645) = 2.2, p = .001. The Time by Group interaction was

also significant, F (24, 645) = 1.7, p = .022. Table 3 shows the Time in Program, Sex, and Group


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averages for the eight dependent measures, with subscripts for the measures where there was a

statistically significant difference for a given factor. The eta square values for significance

differences ranged from .04 to .11, which fall within a medium effect size (Cohen, 1988).

Overall, there were significant reductions in aggression, internalizing, suicide, and use of

seclusions and personal restraints during the residential stay, even after accounting for sex and

group effects. There were univariate differences between males and females for aggression,

covert, hyperactivity, and internalizing behaviors. Males had higher rates of aggression, covert,

and hyperactivity than did females, whereas females had significantly higher rates of

internalizing behavior. All of these gender differences conform to well established patterns in the

literature.

There were significant differences for the Group variable for aggression (although there

was no significant pair-wise comparison), hyperactivity, internalizing, oppositional, suicide,

seclusions, and personal restraints. Bonferroni’s post hoc test was used to examine the pattern of

significant differences for the four medication-pattern groups across the eight dependent

variables (see Table 3). Generally, the Medication Reduction group had the highest averages,

followed by the Medication Increase and Medication Maintenance groups. The lowest averages

were for the No-medication group.

As shown in Figure 1, the general pattern for all dependent measures was for problems to

decrease, with the Medication Increase group often decreasing less or even increasing, and

Covert behavior increasing for the Medication Maintenance group. The univariate Time by

Group interaction was significant for personal restraints, F (3, 220) = 5.3, p = .001; and for

Internalizing behavior, F (3, 220) = 3.6, p < .05. For Internalizing behavior was one of decrease

for all but the Medication Increase group, which showed the smallest decrease. It is telling,

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however, that while Restraints decreased for three of the groups, they increased for the

Medication Increase group.

Discussion

Consistent with much extant research, youth come into the IRTC with high psychotropic

medication rates. The results presented here demonstrate that medication rates can be

significantly reduced for the majority of youth without an increase in emotional and behavioral

problem behaviors or in the use of personal restraint. This result is noteworthy in light of prior

research showing that intensive residential treatment has been associated with increased

medication rates (Zakriski et al., 2005). Clinical improvement, in terms of the broad range of

problem behaviors measured, can occur while reducing medication.

It is paradoxical that in spite of high medication rates at admission to the IRTC, these

youth still demonstrated sufficiently high levels of behavioral disturbance to warrant admission

to a highly restrictive level of care. While the level of emotional and behavioral disturbance for

these youth prior to treatment was unknown, it does not appear that the medications prescribed

produced the intended effect of controlling unwanted behavior. Once within the context of the

IRTC’s intensive behavioral treatment milieu, however, problem behavior did improve and

significant reductions in apparently unnecessary medications occurred. This is clearly seen in the

results for the Medication Reduction group, which were the most troubled for every dependent

measure, but had the steepest slopes for improvement even while they were experiencing

reductions of medications once thought clinically necessary. A strong behavioral intervention

with a daily measure of emotional and behavioral problems allowed the attending psychiatrist to

apply a data-driven approach to making reductions in psychotropic medication. These results


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support the notion that, at least for these youth, high levels of medications were not necessary

with an intensive behavioral approach.

One interesting result was that the number of personal restraints increased for the

Medication Increase group, whereas restraints decreased significantly for all the other groups. It

is not possible from the current data to determine why this may have occurred. One possibility is

that these youth were inappropriately placed and required a more intensive level of care than the

program was designed to provide. Another is that the Medication Increase group included youth

with a mixed response to the treatment, who improved in some ways and had increasing

treatment needs in other ways. Within the treatment program, the use of a personal restraint is

always seen as a failure to deescalate a youth’s aggression. The increase in the number of

personal restraints for this group is suggestive of more serious aggressive events occurring over

time, perhaps in spite of the increased of psychotropic medications to counter these trends.

Identifying the underlying factors associated with a mixed response to treatment in this type of

treatment setting is a question that should be examined in future research.

The use of restraint has been shown to be associated with the severity of an incident,

especially where there is a threat of harm to either self or another person (Dean et al., 2007;

Gudjonsson, Rabe-Hesketh, & Wilson, 2000; Gullick, McDermott, Stone, & Gibbon, 2005). The

results reported here found that overall there were significantly higher rates of aggressive

behavior for boys than for girls, but that there was no difference between girls and boys for the

number of personal restraints. This may be an indication that boys and girls were equally likely

to manifest aggressive behavior that carries a risk of harm to self or others (i.e., the more extreme

forms of aggression). The severity and object of each aggressive act was not accounted for in this

study, but this result is intriguing and deserves further study.


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The high levels of emotional and behavioral problems for youth admitted to this program,

combined with the fact that these youth responded favorably while receiving behavioral

treatment, might suggest that whatever care they had received prior to admission had not met

their treatment needs and perhaps this contributed to the high medication rates. There is clearly a

need for future research to untangle the optimal combination of medical and psychological

interventions for youth with high levels emotional and behavioral impairment in the community

setting to prevent placement in residential facilities. It is clear, however, that for many of these

youth psychotropic medication was not sufficient, nor perhaps even necessary, for clinical

improvement.

In the same way that reducing both aggressive behavior and the use of personal restraint

creates a safer treatment environment for youth, reducing superfluous medications also has

safety implications. Potent psychotropic medications, with known health aversive risks, present

their own hazards for youth. These hazards are exacerbated by polypharmacy and the potential

for drug interactions. These risks may be compounded for troubled youth, who often experience

multiple out-of-home placements and may lack a committed advocate to monitor their response

to medication and side effects over time. Reducing unnecessary medication is consistent with the

goal of treating youth in safest and least restrictive environment possible.

There are several limitations to this study. First, the sample comes from a single

residential treatment center. The results reported here might not apply to other out-of-home

programs using different treatment models with youth facing other types of challenges.

Similarly, the program relies largely on the services of a single psychiatrist. Obviously, the levels

of medication reduction reported are clearly a function of the medication philosophy and

management approach taken by this psychiatrist (Spellman et al., 2010). The lack of a


18

comparison group is also problematic, so there may be other viable explanations for the results

obtained here. Finally, the grouping variable that was created corresponds to naturally occurring

changes in medication among the youth in the program, so other factors may underlie the

differences seen.

Implications for Behavioral Health

It is not our position that every child should be on lower levels of medication. Our

position is that youth should be on the medication(s) they need and no more. Results show that it

is possible to safely reduce rates of psychotropic medication within the context of a clinically

directed psychoeducational treatment milieu. A public health model that should guide the use of

psychotropic medications in pediatric populations is the principle of sufficiency. The principle of

sufficiency states that treatment should involve the minimally sufficient intervention to solve a

problem without creating dependency or other unwanted consequences. The principle of

sufficiency has been identified as a key public health principle (Prinz, 2009), and is especially

relevant in the context of pediatric psychopharmacotherapy.

Additionally, data driven decision making (DDM) provided a means for determining the

sufficient level of medication. DDM in this context was the analysis and use of real-time patient

data in guiding decisions about the use of and making changes in psychotropic medication. More

detail on the DDM approach and program elements used in this program is available elsewhere

(Spellman et al., 2010). Several researchers have argued that DDM has the potential to move

prescribing practices from trial and error to a more scientific process (Chouinard, 2004; LeFever

et al., 2003; Lerer, 2002).

Last, our findings suggest that youth admitted to residential facilities differed in

their responsiveness to a clinically directed psychotherapeutic program, with or without


19

medication use. Combining an intensive program with a DDM approach to medication with

rapid identification of those youth not responding sufficiently to this combination of treatment

may permit early personalization of care for youth with emotional and behavioral impairment.


20

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29

Table 1. Demographic information for IRTC youth

N %

Sex Female 115 50.4%

Male 113 49.6%

Race White 145 63.8%

Black 41 18.1%

Other 41 18.1%

State ward Yes 125 66.1%

No 64 33.9%

Referral Source Mental Health 119 63.9%

Social Service 36 19.4%

Court/JJ 15 8.1%

Parent/Guardian 13 7.0%

Other 3 1.6%

Prior Setting Inpatient 59 31.2%

Juvenile Justice 52 27.5%

Parental home 34 18.0%

Group Care 24 12.7%

RTC 14 7.4%

Foster Care 6 3.2%


30

Table 2. Descriptive statistics for critical incident variables.

Variable Mean SD Range

Oppositional (6 items)

First two weeks

Last two weeks

38.3

29.8

30.6

24.1

0 – 127

0 – 134

Aggression (6 items)

First two weeks

Last two weeks

21.0

7.4

45.4

18.3

0 – 356

0 – 130

Hyperactivity (5 items)

First two weeks

Last two weeks

15.5

13.2

13.0

11.4

0 – 71

0 – 76

Internalizing (5 items)

First two weeks

Last two weeks

11.2

7.4

9.8

7.3

0 – 59

0 – 48

Covert (5 items)

First two weeks

Last two weeks

5.8

4.1

8.2

4.6

0 – 69

0 – 30

Suicide (3 items)

First two weeks

Last two weeks

4.3

0.8

10.5

3.0

0 – 92

0 – 25

Seclusion (1 item)

First two weeks

Last two weeks

1.2

0.4

3.4

1.4

0 – 28

0 – 10

Restraint (1 item)

First two weeks

Last two weeks

1.3

0.4

3.0

1.8

0 – 23

0 – 19


31

Table 3. Estimated marginal means and standard errors for behavioral scales, restraints, and

seclusions for Time, Sex, and Group, with subscripts where there were significant post hoc test

differences.

Time Sex Group

F

irst

2

Wee

ks

Las

t 2

Wee

ks

Mal

e

Fem

ale

Red

uct

ion

Incr

ease

No c

han

ge

No M

ed

M

(SE)

M

(SE)

M

(SE)

M

(SE)

M

(SE)

M

(SE)

M

(SE)

M

(SE)

Aggression 16.3a

(3.7)

6.0b

(1.5)

13.7y

(3.2)

8.6x

(3.2)

18.0

(2.3)

12.4

(5.1)

10.6

(4.8)

3.6

(5.2)

Covert 5.2

(0.7)

4.3

(0.4)

5.8y

(0.6)

3.7x

(0.6)

5.2

(0.4)

5.0

(1.0)

4.7

(0.9)

3.9

(1.0)

Hyperactivity 13.8

(1.0)

12.2

(0.9)

16.7y

(1.2)

9.4x

(1.2)

16.1c

(0.9)

15.6cd

(1.9)

11.1d

(1.8)

9.4cd

(2.0)

Internalizing 9.3a

(0.8)

6.7b

(0.6)

6.9y

(0.9)

9.1x

(0.8)

11.0c

(0.6)

9.3c

(1.4)

7.5c

(1.3)

4.0d

(1.4)

Oppositional 34.4

(2.5)

28.8

(2.0)

34.5

(2.8)

28.7

(2.8)

37.3c

(2.1)

38.0cd

(4.5)

28.8cd

(4.3)

22.3d

(4.6)

Suicide 3.1a

(0.9)

0.6b

(0.3)

1.6

(0.7)

2.0

(0.7)

3.4c

(0.5)

2.9c

(1.1)

0.9cd

(1.0)

0.1d

(1.1)

Seclusion 0.9a

(0.3)

0.3b

(0.1)

0.7

(0.2)

0.5

(0.2)

1.1c

(0.2)

0.8cd

(0.4)

0.4cd

(0.3)

0.2d

(0.4)

Restraint 0.9a

(0.2)

0.3b

(0.1)

0.6

(0.2)

.6

(0.2)

1.1c

(0.2)

0.8cd

(0.3)

0.4cd

(0.3)

0.1d

(0.3)

Figure 1: Interaction plots showing Group by Time interaction for the behavioral scales,

restraints, and seclusions.

reducing psychotropic medications in an intensive residential treatment center

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