title: Measuring the Complexity of Treatment for Challenging Behavior using the Treatment Intensity Rating Form.
abstract: OBJECTIVE
  The goal of this study was to develop and evaluate a tool to measure the complexity and intensity of psychotropic medication interventions, behavioral interventions, and issues related to crisis management for challenging behavior using a standardized rating form.
  
  
  METHODS
  The Treatment Intensity Rating Form (TIRF) is a 10-item scale with three categories: pharmacological interventions, behavior supports, and protective equipment. In a retrospective review we examined the final treatment recommendations for 74 individuals with self-injurious behavior (SIB) based on psychiatric and behavioral notes and reports. We also compared whether TIRF scores differed across individuals for whom SIB was maintained by social reinforcement (e.g., to access attention or toys/activities, or escape from tasks) versus those for whom SIB was maintained by automatic reinforcement (e.g., occurs independent of social variables, and is presumed to be maintained by sensory reinforcement).
  
  
  RESULTS
  The TIRF was demonstrated to have strong inter-rater reliability (98%) and appears to have good face validity. As hypothesized, individuals with SIB maintained by automatic reinforcement had significantly more medication trials (p=0.0005) and required more protective equipment than individuals with SIB maintained by social reinforcement (p=0.0002). Antidepressant medication was used more often with individuals with automatically reinforced SIB, although antipsychotics and anticonvulsants were also commonly used across both groups.
  
  
  CONCLUSIONS
  Findings provide initial support for the TIRF's reliability, and face validity as a measure the level of complexity of medical and behavioral treatment plans - although additional research is needed to fully evaluate its psychometric properties.
authors.affiliation: Kennedy Krieger Institute and Johns Hopkins School of Medicine.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Zarcone
authors.affiliation: Kennedy Krieger Institute and Johns Hopkins School of Medicine.
authors.forename: Louis
authors.initials: L
authors.lastname: Hagopian
authors.affiliation: Kennedy Krieger Institute and Johns Hopkins School of Medicine.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Ninci
authors.affiliation: Kennedy Krieger Institute and Johns Hopkins School of Medicine.
authors.forename: Chloe
authors.initials: C
authors.lastname: McKay
authors.affiliation: Kennedy Krieger Institute and Johns Hopkins School of Medicine.
authors.forename: Andrew
authors.initials: A
authors.lastname: Bonner
authors.affiliation: Kennedy Krieger Institute and Johns Hopkins School of Medicine.
authors.forename: Christopher
authors.initials: C
authors.lastname: Dillon
authors.affiliation: Kennedy Krieger Institute and Johns Hopkins School of Medicine.
authors.forename: Nicole
authors.initials: N
authors.lastname: Hausman
keywords: Behavioral treatment; Challenging Behavior; Complexity; Intensity; Medication; Self-injurious behavior