Discussion:
Topic of the Day
Medication and Data Sharing
with
Multiply Handicapped Students
When I was first asked to write an article for a newsletter on the policy that we
had developed on use of medication within the school to which I consulted, I thought of lots of ideas and more than a few stories - but one
specific story will help in understanding the approach to incorporating
medication into how that school served students.
The story of new medications and how they are advertised is
summed up rather well by the story of "Pep Pills". In the late-1940s
the Veterans Administration Hospitals saw a huge increase in services for
anxiety and a range of odd behaviors from veterans of WWII. All through the war
the military gave servicemen varying degrees of access to "Pep Pills"
and told the GIs that they were "free energy". At the time physicians
saw no down side and no real side effects from the use of stimulants.
These
medications were presented as nearly a miracle for the frequently sleep deprived
GI in need of energy under difficult and dangerous circumstances. The problem is
that, as we now know all too well, stimulants have a range of often very serious
side effects and are anything but "free" energy. Those previously
unrecognized side-effects resulted in the need for all
those psychiatric services for withdrawal effects in the late-1940s in the VA
Hospitals.
No medication, be it aspirin or Zyprexa®, comes without
side-effects. According to a recent study in the Journal of the American
Medical Association1 there has been an alarming increase in
off-label use of psychotropic medications for pre-school children (between 2 and
4 years old) during the 1990's for modification of behavior disorders. Stimulant
treatment alone reportedly increased approximately "3-fold" during the
period examined, however increases were not limited to stimulants but included
Clonidine, Tricyclic antidepressants, and SSRIs. This does not mean that
students do not occasionally need medication. We had00 several students at the
residential schools who came to the school on 5 or more psychoactive medications, several of which
had notes from their psychiatrist of pediatrician stating that the child
"required" those medications. Most of those students were either
behavioral medication free or on greatly reduced numbers and doses of
medications with significant improvements in all problem and adaptive behaviors.
How did we know that there have been specific improvements in
those behaviors? The staff took data on a wide range of behaviors in order
to have specific and accurate information to track any changes in the students
served. This allows for early identification of areas of concern and
identification of progress. The schools had a variety of students who were on
psychiatric medications for problems ranging from severe self-injury to Bipolar
disorder as well as a variety of neurological medications for a range of seizure
disorders. However, it is the
thoughtful and specific use of medications when there are clear reasons for
those specific medications that were set as standards for serving students.
The philosophy is "Lowest effective dose" in order to reduce
side-effects and maximize student access to learning.
That is why we worked so closely with a
psychiatrist to develop an
integrated approach to the use of medication with those students. The staff routinely provided data on the range of behaviors of
concern during psychiatric and neurological consultations in order to make
certain that all medication recommendations were based on accurate and specific
information. This process helped ensure that if a medication was recommended for a
student that it was for a specific problem with measurable indicators of the
effects of the medication. When done well, this process allows for the use of
the minimum effective medication and also allows the physician the opportunity
to make the best recommendations possible for changes in medications for the
students. The essential questions that we strive to make everyone involved in
the process aware of are: is there another way to achieve the same goal without
the medication, if the person does need the medication then how little is
sufficient to treat the problem (typically the less of a medicine the lower the
likelihood of adverse side-effects), and if and when can we shift away from the
medication?
The combination of an awareness that medications can have
serious side-effects, that once in the body medications can have permanent
effects, serve as restraint, and certainly can make learning more difficult, and
that there are often non-medical approaches to changing behavior and improving
skills is how the incorporation of medications into the services that were
provided to the students should be approached.
Dr. Montgomery has presented a workshop entitled: Collaborating with Physicians: Developing a Data-Based process for serving children with psychiatric and neurological
needs to a variety of agencies and conferences. The focus is on
improving the connection between day-to-day issues with the child and the
medications used, if any, to support the child.
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