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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 had 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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