Michael is a BCBA that has worked with a family for over (5) years. Recently, his learner has entered adolescence and he has started to exhibit behaviors best categorized as hyperacti

Behav Analysis Practice (2017) 10:145–153 DOI 10.1007/s40617-017-0184-x

DISCUSSION AND REVIEW PAPER

Ethical Considerations for Interdisciplinary Collaboration with Prescribing Professionals

Mindy K. Newhouse-Oisten1 & Kimberly M. Peck1

& Alissa A. Conway1 & Jessica E. Frieder1

Published online: 5 April 2017 # Association for Behavior Analysis International 2017

Abstract Behavior analysts often work as part of an interdis- ciplinary team, and different team members may prescribe different interventions for a single client. One such interven- tion that is commonly encountered is a change in medication. Changes in medication regimens have the potential to alter behavior in a number of ways. As such, it is important for all team members to be aware of every intervention and to consider how different interventions may interact with each other. These facts make regular and clear communication among team members vital for treatment success. While working as part of an interdisciplinary team, behavior analysts must abide by their ethics code, which sometimes means ad- vocating for their client with the rest of the team. This article will review some possible implications of medicinal interven- tions, potential ethical issues that can arise, and a case study from the authors’ experience. Finally, the authors propose a decision-making tree that can aid in determining the best course of action when a team member proposes an interven- tion in addition to, or concurrent with, interventions proposed by the behavior analyst.

Keywords Interdisciplinary treatment . Ethical considerations . Behavioral interventions . Medications

Imagine being a mental health professional, visiting a long- time client, Mark, at his adult foster care home. While work- ing with Mark, you have helped him learn appropriate behav- iors to use in aversive situations, along with supporting his

* Mindy K. Newhouse-Oisten [email protected]

Department of Psychology, Western Michigan University, Mail Stop 5439, Kalamazoo, MI 49008, USA

staff in navigating through these target behaviors. In the two years you have worked together, Mark has never turned down a visit, and always greets you with a smile; however, today, Mark is quiet and even asks to leave the visit early. When he leaves the room, you look to Mark’s staff for answers. Staff launch into a diatribe of Bnew^ behaviors that have suddenly been occurring over the last week, BHe’s angry all the time, and he’s even refusing medications now.^ Another staff chimes in, BHe keeps making negative statements about him- self and even talks about hurting himself. It just doesn’t make any sense!^

As any professional in this situation, you begin asking questions to assess the situation and try to determine exactly where things started to go awry. Staff explain that there have not been any schedule or staff changes, Mark has not been sick, and there is nothing that has changed that would affect him this way. Staff report it seems like he simply changed Bovernight^; one staff even said that it was as if a Bswitch had flipped.^ Confused by this situation, you ask once more about Mark’s health. You ask staff about any unusual visits to the doctor, and a staff member suddenly lights up, BYou know—when Mark asked the doctor last week for help with his temper, she doubled his normal antipsychotic, do you think that could be a factor?^

The scenario above, and situations like it, is a common occurrence for mental health professionals engaged in inter- disciplinary assessment and treatment. When considering clinical professionals that provide services to clients with mental disabilities, medical physicians, psychiatrists, psychol- ogists, and behavior analysts are only a few on the list of individuals interacting with the client on a regular basis. Each professional role has its individual code of ethical guide- lines, regulated by each profession’s certification or licensing board. With interdisciplinary treatment, it is important to con- sider all ethical codes when delineating who will provide

1

146 Behav Analysis Practice (2017) 10:145–153

which services and when. The ethical guidelines also aid pro- fessionals when identifying the best ways to interact with each other professionally. Unfortunately, these guidelines, while based on research, often leave gaps in outlining interactions among members of the interdisciplinary team across different clinical methodologies.

In an advancing society, ethical standards of each mental health profession are regularly evolving in order to meet the needs of the current treatment climate. Specifically, behavior analysts, althoughmore novice in establishing the ethical stan- dards for their field, highlight the importance of a global ap- proach to behavior analytic interventions (Bailey & Pyles, 1989). While behavior analysts often attend to antecedent and consequent events, it is important for them to be regularly sensitive to the multiple antecedent events that can affect be- havior outside of the scope of their individual practice. These antecedents include medications, as well as other combination therapies and interventions in an interdisciplinary approach to treatment.

In order to collaborate effectively, it is important to be familiar with the ethical standards of practice that guide med- ical physicians, behavior analysts, psychologists, psychia- trists, and other professionals who work as consistent mem- bers of the client’s treatment team. Each discipline offers a unique skill set, specialized training, and a specific approach to treatment. As such, it is important to consider each field when creating a framework for interdisciplinary treatment. The purpose of the current discussion is to highlight the rele- vant literature related to interdisciplinary treatment, review the current ethical standards of mental health professionals, exam- ine a case example to highlight relevant concerns, and outline potential future directions to enhance the current and future practice of mental health treatment teams who are providing interdisciplinary treatment. Furthermore, the current paper will offer a decision-making hierarchy for interdisciplinary teams to employ when determining the most appropriate and evidence-based treatment interventions for their clients.

Effects of Pharmacological Interventions on Motivation and Behavior

In particular, pharmacological interventions can affect the be- havior of individuals and, in turn, affect concurrent behavior interventions. Behavior analysts are ethically required to pro- vide function-based assessment and evidence-based interven- tions and continually monitor progress in the context of inter- ventions (Behavior Analysis Certification Board, 2014). With the addition of medication modifications during treatment, we must monitor and assess in even greater detail. Modifications to medications may cause unobservable biological changes that affect behavior. Early detection allows therapists to make appropriate adjustments to interventions to ensure the best

possible treatment and outcomes. Assessments behavior ana- lysts would normally conduct prior to the start of treatment (e.g., components of a functional assessment) may need to be conducted several times throughout a pharmacological regi- men until some level of stability is achieved (Crosland et al., 2003; Valdovinos, Nelson, Kuhle, & Dierks, 2009). Related to behavioral interventions, researchers have investigated the ef- fects of pharmacological interventions on changes in the value of reinforcers, as well as changes in the function and frequen- cy of behavior (Fisher, Piazza, & Page, 1989; Hoza, Pelham, Sams, & Carlson, 1992; Northup, Fusilier, Swanson, Roane, & Borrero, 1997; Larue et al., 2008). The effects are not al- ways detrimental, but do highlight the necessity for continu- ous monitoring of these interventions and relevant behavior changes to determine the need for any adjustments. An analogous example in the medical field would be the prescription and monitoring of allergy medications. Individuals may already have issues related to blood pressure and must report this to the physician because this would impede the prescription of allergy medications that may further increase blood pressure. The individual must also continue to report side effects of medications, such as headaches, changes in appetite, or fatigue, after a prescription is in place. The physician would then make changes, such as amount or time of dosage, to the medical intervention to alleviate these effects.

Valdovinos and Kennedy (2004) provide a behavior ana- lytic conceptualization of the potential side effects of pharma- cologic treatments on behavior interventions. They describe how medications may act as motivating operations; for in- stance, one side effect may be appetite suppression, often as- sociated with the stimulant methylphenidate. For example, methylphenidate may decrease the effectiveness of edible re- inforcers as the individual is no longer motivated by food. While non-edible reinforcers may be more appropriate rein- forcers overall, if an edible stimulus is being used as a rein- forcer, it would be important to identify any changes in moti- vation with respect to edibles as soon as the change occurs. Otherwise, the therapist may assume problems with the be- havioral intervention when it is indeed successful. Furthermore, medications may alter discriminative or condi- tional stimulus control. Side effects such as fatigue or pain may act as discriminative or conditional stimuli that may evoke unusual behavior (e.g., avoidance, escape, engagement) as compared to behavior prior to medication changes. An example of this change may be associated with the side effect of fatigue often related to benzodiazepines and antihistamines. The individual might have difficulty staying awake; vision and other senses could be impaired and cause avoidance of demands. Finally, Valdovinos and Kennedy (2004) discuss how possible effects on response-reinforcer relations can oc- cur. The side effects can act as positive or negative reinforcers or punishers and further affect application of the medication.

147 Behav Analysis Practice (2017) 10:145–153

An example may include the side effect of nausea that causes an individual to stop taking medication to prevent effects, which would result in negative reinforcement. Alternatively, an individual might find a medication causes muscle relaxa- tion as a side effect and may take more medication than nec- essary to increase the effects (positive reinforcement) (Valdovinos & Kennedy, 2004).

Researchers have investigated the components described above to analyze the effects of medication-specific changes on reinforcer effectiveness and how to assess them accurately. During medication changes, individuals have been shown to select alternative reinforcers (e.g., toys instead of edibles, play with others instead of play alone) to those indicated during original baseline or placebo assessments (Northup et al., 1997; Larue et al., 2008). Reinforcer assessments can be utilized to determine changes in reinforcer preference as a result of phar- macological intervention.

An additional way to assess the side effects of medications is throughexperimentalanalysis during assessmentprocedures.For example, functional analyses can be conducted throughout phar- macological treatments to determine the effects of various levels of medication on both frequency and function of behaviors. Croslandetal. (2003)foundthat thepharmacological intervention of risperidone affected participants differently across conditions (e.g., attention, demand, and tangible), as well as across topogra- phies of behavior (e.g., self-injurious behavior versus aggression toward others). The participants varied in frequency of problem behavior during conditions, and one participant changed topography of behavior due to medication changes. Valdovinos et al. (2009)also utilized this typeofassessmentandfound similar results. Changeswerenotconsistent across individualsandvaried across conditions of the assessment and levels of medication ad- ministered. Functional analysesmayalsobeutilized todetermine behavioral effects of behavior interventions alone or in combina- tionwith pharmacological interventions (Fisheret al., 1989;Hoza et al., 1992). If the changes in medications are known, reinforcer assessments, as well as functional analyses, may need to be con- ducted immediately. If the changes are unknown, the behavior analyst may mistakenly provide ineffective intervention(s) for an extended period of time.

Efficacy of Pharmacological and Behavioral Interventions

In addition to research demonstrating effects of medication on motivation and behavior, many studies have been conducted to directly compare medications to other treatments. Although no studies exist that directly compare medications to treat- ments that are solely based on applied behavior analysis, sev- eral studies have compared medications to placebos, cognitive behavioral therapy, and combination treatments. Such studies are still important to be familiar with and understand for

several reasons. First, they can help professionals to under- stand the potential advantages and disadvantages of pharma- cological interventions. Second, cognitive behavioral thera- pies often contain components of applied behavior analysis, and the procedures and effects of such therapies can be interpreted using the principles of behavior.

One such comparison study, the Child-Adolescent Anxiety Multimodal Study (CAMS), compared the efficacy of sertra- line, a selective serotonin reuptake inhibitor (SSRI), to three other treatment conditions: cognitive behavioral therapy (CBT), pill placebo, and combination of sertraline and CBT (Piacentini et al., 2014; Walkup et al., 2008). Medications were regularly monitored and titrated based on reported anx- iety levels during monitoring visits. CBT included anxiety management and behavioral exposure. Treatments were ad- ministered for 12 weeks, and measures of symptom frequency and severity and adverse effects were obtained pre-treatment and after 4, 8, 12, 24, and 36 weeks. Subjects were 488 chil- dren and adolescents between the ages of 7 and 17 years with diagnoses of separation anxiety disorder, generalized anxiety disorder, or social phobia.

Initially, the group that received both sertraline and CBT displayed the greatest improvement, followed by the CBT- only group and then the sertraline-only group. Over time, the other groups began to show more improvement as well, but after several weeks, the medication-only and combination groups began to demonstrate a worsening in symptoms again, while symptom measures of the CBT-only group began to stabilize. This latter group also experienced the fewest number of physical side effects throughout the study.

Patterns similar to those seen in the CAMS can be found in other comparison studies (Garcia et al. 2010;MTACooperative Group 1999; Murray et al. 2008; TADS Team 2004). For ex- ample, the Multimodal Treatment Study of Children with Attention Deficit/Hyperactivity Disorder (MTA) compared ti- trated administration of methylphenidate hydrochloride to be- havioral treatment, a combination of medication and behavioral treatment, and community care (i.e., treatment as usual, in which the subject’s families were given a list of resources avail- able in the community and sought treatment through other pro- viders in their community (MTA Cooperative Group, 1999; Murray et al., 2008). This study found that the combination treatment (medication and behavioral treatment) had a greater effect in the early weeks of the study, but differences in effect decreased until there were no longer any significant differences between groups in symptom improvement. Adverse effects varied by group, but were greater for the medication-only group, which was also associated with a slowing of physical growth in comparison to the other groups.

There are often several limitations to such comparison studies. First, they frequently have strict inclusionary and ex- clusionary criteria that limit the generalizability of such stud- ies to other populations (e.g., populations with comorbid

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diagnoses or with lower socioeconomic status). Additionally, measures are often based on informant report from both the subjects and their parents, which means direct measures of symptoms are lacking. These limitations point to a need for more objective measurements and for carefully monitoring treatments with individual clients, especially clients who dif- fer substantially from the available studies.

In contrast to the studies described above, very little evi- dence is available to support the use of drug treatment in children with autism spectrum disorders. Yet, the authors often encounter clients diagnosed with autism who are prescribed some medications. McPheeters et al. (2011) conducted a re- view of medical treatment studies for children 12 years old or younger with autism and found that some evidence exists to support the use of titrated risperidone and aripiprazole for decreasing challenging and repetitive behaviors; however, both medications were also associated with significant adverse effects, such as weight gain and sedation. Insufficient evi- dence was found for efficacy in symptom improvement or for adverse effects of other medications for children with au- tism. In contrast, a variety of large-scale studies have provided support for the long-term efficacy of behavioral treatments in improving symptoms of autism, and these treatments are not associated with a high risk of adverse effects (e.g., Dawson et al., 2010, 2012; Eikeseth, Smith, Jahr, & Eldevik, 2007).

These examples illustrate several other considerations that must be taken into account when behavior analysts work with a client alongside a prescribing professional. Behavior analysts may be able to help provide objective measurements of symp- toms or behaviors the prescribing professional hopes to address with the medication, including data from multiple environ- ments and in comparison to behavioral interventions, which will aid in making data-based decisions regarding client treat- ment. Another consideration involves weighing the advantages and disadvantages of different treatments before deciding on the best course of action. Behavior analysts and prescribing professionals can work together to do so and should consider not only potential effects on the targeted behaviors but also adverse side effects, impact on motivation and other factors, time and cost of implementation, and client or guardian pref- erences. Researchers throughout the literature stress the impor- tance of collaboration between medical professionals and be- havior analysts, as it may be detrimental to the client to work independently (Valdovinos et al., 2009). Professionals can share information about relevant interventions to assist one another in choosing the best possible treatment based on re- peated assessments for the individual involved.

Ethical Guidelines

The authors reviewed the American Medical Association’s (AMA) Medical Code of Ethics, the American Psychiatric

Association’s Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry, the American Psychological Association’s (APA) Ethical Principles of Psychologists and Code of Conduct, and the Behavior Analyst Certification Board’s (BACB) Professional and Ethical Compliance Code for Behavior Analysts in order to identify the standards of care related to consultation with mul- tiple professional agencies. These codes were selected for re- view, as behavior analysts often collaborate with these profes- sionals on global treatment decisions in consultative, interdis- ciplinary care. The codes were also reviewed to determine the guidelines for collective recommendations for treatment (as well as any changes made to treatment) among mental health professionals. Identifying the similarities and differences in core values for each member of the interdisciplinary team will enhance collaborative discussion and aid in treatment ac- countability overall (Vinokur-Kaplan, 1995).

Throughout each code of conduct, there is an overarching echo of Bdo no harm.^ Each profession supports the mission that in all services delivered, it is most important to keep the client’s well-being and safety at the forefront of treatment. In collaborative treatment, this means striving for the most ap- propriate and effective combination of treatment and some- times peer review (American Psychiatric Association, 2001). Professionals involved in each case will need to notify rele- vant treatment team members of changes in medication regi- mens, therapies, or programming. As noted above, communi- cating these changes is essential to avoid any problems that could arise from contraindicated interventions.

Additionally, all codes of conduct discuss their responsibil- ity to the client. Responsibility is an umbrella term used for a number of professional obligations to the client, but it ulti- mately means that mental health professionals advocate for their clients’ overall well-being. This charge also specifies that professionals are mandated to report any concerns of harm or ethical violations that may occur during treatment (American Psychiatric Association, 2001; American Psychological Association, 2007; Behavior Analyst Certification Board, 2014). One responsibility of mental health professionals is that they only work within the boundaries of their compe- tence. This is one reason why collaborative care is so impor- tant (Behavior Analyst Certification Board, 2014). Professionals should communicate with one another about treatment, but ultimately defer specific decisions to the pro- fessionals with the most expertise and training in a given treat- ment area (e.g., when medications are prescribed by a psychi- atrist or medical physician, the decision should ultimately be made after a discussionwith the overall treatment team, so that an informed treatment decision can be made about how that change may affect other current treatments) (American Psychological Association, 2007).

Specifically, the codes of conduct for both the APA and the BACB stress the need for assessment and collaboration in

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treatment. They purport that treatment should be individualized to each client, based on their specific needs. Precise examination and assessment provide information needed to prescribe appro- priate interventions. Furthermore, both encourage consultation with medical professionals in order to provide the client with the most conclusive and effective treatment. Medical professionals are often able to rule out and identify health-related and biolog- ical concerns that can impede behavioral or psychological treat- ment (American Psychological Association, 2007; Behavior Analyst Certification Board, 2014).

Case Example

To illustrate the points above, the comprehensive case exam- ple below highlights the potential ethical dilemmas faced and how the authors handled them throughout the assessment and intervention process.

The authors received a referral for a preschool-aged child with diagnoses of autism spectrum disorder, attention deficit hyperactivity disorder (ADHD), hoarding disorder, and bipo- lar II disorder. The child, whom we will refer to as Jason for our purposes here, was originally referred to our treatment team for behavioral services due to erratic sleep patterns af- fecting activities of daily living. We intended to begin the assessment process by conducting functional assessment in- terviews and direct observations and by training caregivers to collect relevant data on target behaviors. Multiple medication changes occurred during the assessment period, each followed by drastic changes in behavior. Behavior problems no longer included just erratic sleep patterns but also severe self- injurious behavior and physical aggression toward others.

During this time, it was important to maintain communica- tion among the entire treatment team to ensure everyone was aware of each intervention change and following changes in behavior. Ongoing assessment allowed the behavior analyst to notice behavior changes and extend assessment until stability in data could be achieved. During the continuous assessment, Jason was hospitalized twice in an attempt to stabilize his behaviors, so that the guardian would feel comfortable bring- ing him back to the home environment. During his time at the hospital and following his discharge, new prescribing profes- sionals were added to the treatment team including a hospital physician and an additional psychiatrist. Along with the addi- tion of new members to the treatment team, also came the addition of new perspectives and intervention methodologies. In an attempt to provide ethical evidence-based treatment ac- cording the BACB guidelines, the authors monitored the phar- macological and relevant environmental changes through data collection and record reviews. Each change was noted through a phase change in a visual graphic display of each target be- havior to display during group treatment team reviews. Continuous communication continued to be required across

the treatment team of prescribing professionals, BCBA, and guardians to advocate for the client to receive the best possible interventions. When possible, communication occurred in person with the guardian, but most communication time was spent sharing information via phone calls and emails, multiple times a week with the entire treatment team.

The assessment process has continued throughout interven- tion as pharmacological changes continue to occur regularly with a plan to fade medication dosages over time. We request- ed monthly medication reviews as part of the behavior plan, as any changes or side effects will likely impact behavioral ser- vices. Meetings have also been arranged where the individ- ual’s treatment team (case managers, staffing agency, BCBA, and guardian as necessary) meets twice a month to review any concerns related to the individual. These meetings allow for in-person timely communication without the barriers of email or phones.We continue to strategize to make necessary chang- es to the intervention environment to account for changes in motivation and preferences due to the possible pharmacolog- ical side effects. While deciding on these changes, we have continued to advocate for compatible and evidence-based in- terventions for the client.

Recommendations for Practice

In consideration of the current research, ethical guidelines, clinical practices, and case examples presented, the authors feel there are a number of ways to enhance interdisciplinary treatment. Models for interdisciplinary treatment have been proposed throughout the literature, such as the Checklist for Analyzing Proposed Treatments (CAPT) (Brodhead, 2015). The current authors are presenting an alternative model with specific considerations and strategies based on what we have found to be most beneficial in current practice, specifically when collaborating with prescribing professionals. Figure 1 outlines a decision-making hierarchy the authors propose for use when making decisions during interdisciplinary treatment. The development of this decision-tree occurred through ongo- ing examination and documental commonalities across sever- al case interactions, considering ethical obligations, and con- sulting with other professionals in the field. A more in-depth description of this decision-making tree follows.

Universal Strategies

It is important for all members of a treatment team, including behavior analysts, psychiatrists, general health providers, oth- er therapists, caregivers or guardians, and the client, to regu- larly communicate with each other and to be aware of inter- vention changes made by any member of the treatment team (American Medical Association, 2007; Behavior Analyst Certification Board, 2014). A number of universal strategies

150 Behav Analysis Practice (2017) 10:145–153

Universal Strategies

Assess

caregiver,

guardian, and

client

preference.

Analyze pros

and cons

(include data

analysis for

intervention

already in

effect).

Advocate for

intervention to

not be

implemented.

Analyze pros

and cons.

Advocate for

intervention to

not be

implemented

OR continue

with universal

strategies.

EB

& C NEB

& C

NEB

& IC EB

& IC

Intervention

Change

Fig. 1 Decision-making process for ensuring intervention compatibility and use of evidence-based interventions. EB evidence-based, NEB not evidence-based, C compatible, IC in

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