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The use of medication in the treatment of challenging
behaviour

Professor Tony Holland, Department of Psychiatry, University of Cambridge

Introduction

The use of medication is but one potential intervention that may, when appropriately used, help
to reduce the frequency and severity of challenging behaviour affecting people with learning
disabilities. However, given the complexity of, and multiple possible reasons for such
behaviours, this information sheet should be read in conjunction with other information sheets in
this pack.

Challenging behaviours may occur for multiple reasons and effective intervention is dependent
on being able to identify the developmental, biological, psychological, and social factors that
may have predisposed to, precipitated, or be maintaining the challenging behaviour in any
individual. It is this understanding that informs intervention and this is particularly true when it
comes to the use of medication. Superficially similar behaviours may arise for different reasons
and therefore intervention is only likely to be effective if the particular reasons in the individual
and his/her environment have been identified and interventions tailored for that individual.
Medication should only be prescribed following a proper assessment and where a clear
rationale for medication use has been identified.

There is a long history of excessive and inappropriate use of usually major tranquillising
medication (referred to as neuroleptic medication), such as chlorpromazine, for “treating”
challenging behaviour. On these occasions the logic appears to have been that someone has been
aggressive or self-injurious and therefore needs “tranquillising” and therefore “major
tranquillisers” should be used. This is a serious misunderstanding of how medications should be
used. The inappropriateness of this type of approach has been confirmed in a recent publication
by Tyrer and colleagues in the Lancet. They reported that the routine use of such medication in
the management of challenging behaviour brings no additional benefit.

The diagnostic process as a guide to prescribing

Medications used in psychiatric and neurological practice have been developed and tested for the
treatment of specific illnesses. For example, this includes anti-depressant medications in the
case of depression, anti-psychotic medications for the treatment of psychosis, and anticonvulsants
to reduce seizures in the case of epilepsy.

In all of these examples, the efficacy of the particular medications concerned will have been
tested using what are referred to as “double-blind placebo-controlled trials” for the treatment of
the respective illnesses in the general population. They will have been found to be either as or
more effective than existing treatments or more effective than a placebo. These medications
therefore have been licensed for the treatment of those particular disorders. The list of such
medications, the recommended doses and reported side effects are given in the “British National
Formulary“, which is updated on a yearly basis.

Risk benefit analysis

Given the above, the prescribing of medication requires both a diagnostic assessment and a “risk
benefit” analysis. The doctor concerned needs to make a judgement as to whether the likely
benefits of the medication outweigh any likely disadvantages with respect to the potential side
effects. This is no different from the instigation of any other form of intervention, such as
behavioural strategies, where the benefits must be judged to outweigh the potential
disadvantages. This always requires a judgement to be made and there will be times when that
judgement turns out to be incorrect but such a possibility is minimised if the right procedure is
followed.

Site of action of medication

The medications used in the context of challenging behaviour affecting people with learning
disabilities almost invariably will have their actions on the brain. Oral medications are absorbed
through the gut and into the bloodstream. They travel with the blood and those that are able to
do so cross over what is referred to as “the blood-brain barrier” and thereby enter the brain.
In the brain, medications will have particular actions, for example, in terms of stabilising brain
activity (in the case of anticonvulsants) or by acting on specific receptors that are part of one of
many different “neurotransmitter systems”. For example, it is thought that anti-psychotic
medication may act on the dopamine systems in the brain and anti-depressants on the 5-
hydroxytryptamine (serotonin) systems in the brain.

One of the significant advances in psychiatric practise is that new medications are being
developed that have very specific actions on particular neurotransmitter systems that are thought
to be dysfunctional in the context of psychiatric illnesses such as depression, schizophrenia, etc.
Given the fact that people with learning disabilities have an increased risk of epilepsy, one
concern with some of this medication whose action is on the brain is the possibility that seizure
control may deteriorate, or people who previously did not have seizures might have their
“seizure threshold” reduced and therefore increase the risk that seizures might occur for the first
time.

In considering whether to use such medication, such factors have to be balanced against the
potential benefits, and specific antidepressant medications are thought to be better where
epilepsy is a possibility (see risk benefit analysis).

Length and course of treatment

In addition to determining what medication to give, it is necessary to determine for what length
of time the medication should be given. In practice there are three common situations:

First, medication may be given on a one off basis, for example, in a crisis situation (often
referred to as on “a prn” basis). This is the use of medication in the short term to help manage a
particular problem and it is only given when that problem occurs. Examples include the use of
rectal diazepam or buccal midazolam for the treatment of repeat seizures in a short space of time
(“status epilepticus”) or the use of sedative medication when a person is extremely distressed or
anxious.

Secondly, medication can be given for a specific period of time to treat an identified illness. The
best example of this is outside the field of psychiatry and is the use of antibiotics to treat an
infection. In psychiatric practice the use of anti-depressants will usually be time limited
depending on response to treatment.

Thirdly, medication may be used over the longer term and sometimes for life. In these cases
medication does not ‘cure’ the illness but whilst it is being taken effectively controls it. This may
include the use of anticonvulsant medications for treating epilepsy or the long-term use of
antipsychotic medication for treating psychotic illness. In these cases, any judgement about the
long-term use of medication needs to be made over time and the decision to continue will largely
depend on how individuals have responded to medication and whether there is evidence of a
relapse when such medication is reduced.

Medication and challenging behaviour: some general principles

The prescribing of medication in the context of challenging behaviour affecting a person with a
learning disability therefore is a process with specific stages as follows:

There should be a detailed analysis of the reasons for a person’s challenging behaviour.
This will often require the skills of different disciplines and the collecting of data over
time.
The bringing together of evidence from the history, often given by an informant, and the
examination of a person’s physical and mental state in order to identify whether the
person’s challenging behaviour might be occurring in the context of a psychiatric illness,
such as that of depression, mania, psychotic illness, or dementia. In addition, physical
disorders must also be excluded and such illness, if identified, may also require use of
medication, for example, antibiotics to treat infections or the use of painkillers if
someone is in discomfort.
If a diagnosed psychiatric or neurological disorder is present, then medication may be
prescribed that is known to be effective in treating such a disorder. In the case of people
with the learning disability who already are likely to have an abnormality of brain
function and development, the prescribing of medication whose action is on the brain,
needs to be undertaken with care. Starting doses are usually less and have to be
increased carefully depending on observations of the person and information from
informants.
The continued prescribing of medication will depend on the response to treatment and
any concerns about the occurrence of possible side-effects. A further ‘risk benefit
analysis’ should again be carried out having started medication. In the case of anticonvulsants,
outcome measures would include frequency and severity of seizures, and in
the case of depression, mania, or psychotic illness whether the persons mood and mental
state had improved. Where the underlying problem (e.g., epilepsy, depression etc) is
thought to be a factor in the cause of the person’s challenging behaviour the relationship
between any improvements in the above and the frequency and severity of the
challenging behaviour should also be monitored.
The regular use of medication should be with the person’s consent (or in the case of a
child the parent’s or guardian’s consent) or, if the person lacks the capacity to consent,
the medication should given in line with the legislation of the country where the person is
living. In England and Wales this is the Mental Capacity Act 2005 (MCA) and in
Scotland the Adults with Incapacity (Scotland) Act 2000. In the case of the former
treatment can be given to a person unable to consent to that treatment if it is considered
to be in his/her ‘best interests’*. The MCA 2005 and its Code of Practice sets out how
best interests should be determined. In some cases, where the medical treatment is
considered to be serious and there are no family or friends to consult, an Independent
Mental Capacity Advocate (IMCA) should be appointed. In Scotland and Northern
Ireland and in other legislation the conditions set down in common law or in statute
should be met.

*Note (from the Mencap heath factsheet – used with permission): ‘Best interests’ is not
just what the treating health professional thinks is best for the person, but is about what
that person would want if they were able to make their own decision. This should be
based on the values, wishes and beliefs of the person with a learning disability, and the
treating health professional should consult with relatives and carers about this.

The use of medication to treat ‘specific behaviours’ and in situations of uncertainty

With developments in neuroscience and as our understanding of challenging behaviour improves
then there may be the possibility of the use of specific medications under very particular
circumstances for the treatment of ‘behaviours’ such as self-injurious behaviour. Already
neuroleptic medications and medications that affect pain pathways (naloxone) have been used in
the case of severe self-injurious behaviour. This is a complex area and is likely to develop further
in the future.

Whilst the diagnostic process should guide prescribing in the field of learning disability this can
be problematic. Obtaining the necessary information can be more difficult if the person has
limited language and cannot easily describe how they are feeling. It may therefore, on certain
occasions, be acceptable to prescribe medication in situations of some uncertainty, providing the
rationale is clearly established and the monitoring of outcomes is in place.

The key questions that should always be asked are:

For what reasons is the medication being prescribed?
What underlying disorder is thought to be present and is it known to respond to
medication?
What are the potential risks and benefits of such treatment?
How will the outcome of the intervention be monitored?
For how long and at what dose will the medication be given and what reviews will be
undertaken?
Has the person given consent, or does he/she lack the capacity to consent and if so is its
use in that person’s best interest? Where medication is given, particularly in an
emergency, what is the legal justification for such an intervention?

Common medications in psychiatric and neurological practice

a) Antipsychotic medication

One of the first effective psychiatric medications to be developed was chlorpromazine
(Largactil). This medication was shown to reduce the hallucinations and delusions that were
known to occur in those affected by major psychotic illness, such as schizophrenia. This and the
subsequent “neuroleptic medications” became known as major tranquillisers or antipsychotic
medication. There is now a new generation of such medication including, for example,
risperidone, olanzapine and quetiapine.

Psychotic illness is generally considered to be a disorder that usually occurs for the first time in
adult life and is characterised by a change in the person’s mental experiences, such as the onset
of hallucinations or delusions, and/or a deterioration in a person’s ability to think. This can be
difficult to diagnose in people with more severe learning disability but a good history makes it
possible to diagnose such illnesses, if they occur, in people with spoken language and less severe
learning disabilities.

If there is evidence that a person’s challenging behaviour has developed for the first time in the
context of a developing psychotic illness, then the use of such medication is appropriate and is
likely to be effective in reducing the abnormal experiences suffered by the person concerned and
the associated challenging behaviours.

This group of medications are associated with short and longer-term side effects often affecting
the motor systems of the body and leading to some rigidity or tremor. Such risks can be
minimised by keeping to the lowest dose and careful monitoring of how much medication is
needed.

b) Anti-depressant medication

Like the neuroleptic medications, these medications have developed over time and are now
generally very effective in the treatment of depression. The most commonly prescribed
antidepressants are from the group referred to as the selective serotonin reuptake inhibitors
(SSRIs).

Depression is something that can occur during life, and is usually characterised not only by a
deterioration in a person’s mood, sometimes with associated tearfulness, but also in a change in
sleep pattern, often a loss of appetite (or occasionally an increase of appetite), and a loss in
concentration and in general interest. Sometimes there is a diurnal variation whereby someone
tends to be worse at a particular time of the day. Depression, particularly in people with learning
disabilities, can be associated with increasing irritability and poor concentration and therefore
may present with the onset of, or deterioration in, pre-existing challenging behaviours.

Some of the new anti-depressants are also helpful in those with significant anxiety or obsessive
behaviours. In choosing which anti-depressant to use, consideration needs to be given to the
exact characteristic of the depressive illness, and if anxiety or obesssional features are a key
feature, then certain anti-depressant medications may be more helpful than others.

c) Mood-stabilizing medication

A well-recognized psychiatric illness is referred to as bi-polar disorder or manic-depressive
illness. Such illnesses are characterised by extreme fluctuations in mood including periods of
depression to episodes of ‘hypomania’ or ‘mania’. In the case of hypomania (a lesser form of
mania) or mania a person can become very over-active, disinhibited, and irritable.

Treatment of bipolar disorder may include the use of both anti-depressant and major
tranquilising medications depending on the person’s mental state. Longer-term treatment could
also include the use of specific anti-convulsant medications that have also been shown to be
effective in the stabilisation of abnormal mood states and are in this context referred to as “mood
stabilisers” (e.g., carbamazepine, sodium valproate and lamotrigine). The medication lithium can
also be used.

The use of this medication has to be monitored regularly through the use of blood tests to check
levels of the medication in the blood. The reason for this is that, unlike many other medications,
the therapeutic level and the toxic levels are close to each other. Also kidney function and the
function of the thyroid gland should be monitored where lithium is used as the kidney and
thyroid gland can be adversely affected by lithium use.

d) Sedative and anti-anxiety medications

This is potentially a more problematic area for the prescription of medication. As described
above some anti-depressant medications can reduce anxiety and may be of considerable value.

The main group of sedative medications are referred to as the ‘benzodiazepines’ and include
medications such as diazepam (valium). Their long-term use is not recommended because of the
risk of becoming dependent but they are used occasionally in acute situations on a ‘prn’ basis.
Where a person has become highly aroused and frightened such medication may be of value as
part of an established plan that includes a range of strategies aimed at preventing challenging
behaviour arising and managing it when it does occur.

The use of medication under these circumstances must be monitored very carefully and issues of
consent or the legal justification for its use carefully addressed.

e) Anti-convulsant and other medications

As described above anti-convulsant medication may also be used as “mood stabilising”
medication. However, occasionally challenging behaviour may occur in relationship to seizures.
Under these circumstances the treatment of the epilepsy may result in a reduction in the
challenging behaviour. Careful observations are required to disentangle the role of epilepsy in
such situations but if such a relationship was found to exsist the treatment of epilepsy with anticonvulsants may be useful in reducing challenging behaviour. There are an increasing number of
anti-convulsants and the choice of what to use largely depends on the exact type of epilepsy.

Particularly in older people with Down’s syndrome the onset of the memory and cognitive
problems associated with dementia may result in changes in behaviour. Increasingly medications
are being developed that may temporarily improve functioning and thereby behaviour. The best
know of such ‘anti-dementia’ medication is that of donepezil.

Conclusions

Medication may have a role to play in the treatment/management of challenging behaviour. If it
is used it should be for clearly defined reasons and in the context of a specific treatment plan.
Special care needs to be taken as people with learning disabilities (or possibly with specific
syndromes) may be more at risk for adverse affects. Where challenging behaviour may be due to
an underlying psychiatric illness, such as depression, the effective treatment of the depression is
likely to be of considerable benefit. Future research in this area is likely to result in the
development of further medications that will be of significant benefit in the future in the
management of challenging behaviour where there are clearly biological factors that are
contributing to such behaviours.

The use of medication in the treatment of challenging behaviour