Practical Psychotropic Drug Practical Psychotropic Drug Management in Management in Developmental DisabilitiesDevelopmental Disabilities

Craig A. Erickson, Craig A. Erickson, M.D.M.D.

Director, Developmental Disability Research and Treatment Director, Developmental Disability Research and Treatment in Psychiatryin PsychiatryDirector, Fragile X Research & Treatment CenterDirector, Fragile X Research & Treatment CenterMedical Director, P3 Southwest Neurodevelopmental Medical Director, P3 Southwest Neurodevelopmental Disorders Inpatient UnitDisorders Inpatient UnitDirector of Research, The Kelly O’Leary Center for Autism Director of Research, The Kelly O’Leary Center for Autism Spectrum DisordersSpectrum DisordersAssociate Professor of PsychiatryAssociate Professor of PsychiatryCincinnati Children’s Hospital Medical CenterCincinnati Children’s Hospital Medical CenterUniversity of Cincinnati College of Medicine- AffiliatedUniversity of Cincinnati College of Medicine- Affiliated

Conflicts of InterestSource Consultant

(past* or present^)

Stock or Equity Interest

Speakers Bureau

Research Support (past* or present^)

Honorarium/Support for this Talk

Bristol-Myers Squibb X*

Roche/Genentech X* X*

Seaside Therapeutics X* X*

Novartis X* X*

Confluence Pharmaceuticals

X^ X

US Dept of Defense X^

AACAP X*

FRAXA Research Foundation

X*

Alcobra X^ X^

Neuren X^

Simons Research Foundation

X^

Autism Speaks X^

Cincinnati Children’s Hospital Research Foundation

X^

John Merck Fund X^

National Fragile X Foundation

X^

RoadmapRoadmap

Target symptom approach to Target symptom approach to treatmenttreatment

PRN medicationsPRN medications PolypharmacyPolypharmacy Medication DiscontinuationMedication Discontinuation Vignette ExamplesVignette Examples

Target Symptoms for Target Symptoms for MedicationMedication

Motor hyperactivity and inattentionMotor hyperactivity and inattention Interfering ritualistic behaviorInterfering ritualistic behavior Aggression, self-injury, property Aggression, self-injury, property

destructiondestruction

Target Symptoms Target Symptoms Continued:Continued:

Mood disturbances: depression, Mood disturbances: depression, bipolar bipolar

Anxiety: panic attacks, agoraphobia, Anxiety: panic attacks, agoraphobia, general anxiety, phobia, PTSDgeneral anxiety, phobia, PTSD

Others: sleep disturbances, pica, Others: sleep disturbances, pica, inappropriate sexual behaviorinappropriate sexual behavior

Motor Hyperactivity and Motor Hyperactivity and InattentionInattention

Psychostimulants: methylphenidate, Psychostimulants: methylphenidate, dextroamphetamine, mixed dextroamphetamine, mixed amphetamine saltsamphetamine salts

Alpha-2 agonists: guanfacine, Alpha-2 agonists: guanfacine, clonidineclonidine

Non-stimulants: atomoxetine, Non-stimulants: atomoxetine, bupropion, tricyclic antidepressantsbupropion, tricyclic antidepressants

PsychostimulantsPsychostimulants

Work quicklyWork quickly Side effects: reduced appetite, Side effects: reduced appetite,

insomnia, tics, increased pulse/blood insomnia, tics, increased pulse/blood pressurepressure

May cause behavioral worseningMay cause behavioral worsening May need to be given multiple times May need to be given multiple times

per dayper day Need new prescription each monthNeed new prescription each month

Alpha-2 AgonistsAlpha-2 Agonists

Need to monitor blood pressure and Need to monitor blood pressure and heart rateheart rate

Can be sedatingCan be sedating Generally don’t make symptoms Generally don’t make symptoms

worseworse Need to be given 2-3 times per dayNeed to be given 2-3 times per day

Non-StimulantsNon-Stimulants

Atomoxetine: effective in ADHD; Atomoxetine: effective in ADHD; preliminary studies in developmental preliminary studies in developmental disabilities. disabilities. May take longer to work than May take longer to work than

stimulants. stimulants. Generally won’t make tics worse. Generally won’t make tics worse. May help with comorbid mood and/or May help with comorbid mood and/or

anxiety. anxiety.

Non-Stimulants (Cont’d)Non-Stimulants (Cont’d)

Bupropion: has been shown to be Bupropion: has been shown to be effective for ADHD. effective for ADHD. Not well-studied in developmental Not well-studied in developmental

disabilities.disabilities. Can lower the seizure threshold and Can lower the seizure threshold and

should NOT be given to a patient with a should NOT be given to a patient with a history of seizures or active seizure history of seizures or active seizure disorder. disorder.

Can make tics worse.Can make tics worse.

Non-Stimulants (Cont’d)Non-Stimulants (Cont’d)

Tricyclic antidepressants: not well-Tricyclic antidepressants: not well-studied in developmental disabilities. studied in developmental disabilities. Associated with side effects including: Associated with side effects including:

dry mouth, blurry vision, constipation. dry mouth, blurry vision, constipation. Can lower the seizure threshold. Can lower the seizure threshold. Can affect cardiac rhythm. Can affect cardiac rhythm.

Ritualistic BehaviorRitualistic Behavior

Selective Serotonin Reuptake Inhibitors Selective Serotonin Reuptake Inhibitors (SSRIs)(SSRIs) FluoxetineFluoxetine FluvoxamineFluvoxamine SertralineSertraline ParoxetineParoxetine CitalopramCitalopram EscitalopramEscitalopram

SSRIsSSRIs

Data indicate SSRIs may be more Data indicate SSRIs may be more effective in post-pubertal vs. pre-pubertal effective in post-pubertal vs. pre-pubertal individuals with developmental disabilitiesindividuals with developmental disabilities

Side effects: insomnia, sedation, stomach Side effects: insomnia, sedation, stomach upset, sexual dysfunction, weight gainupset, sexual dysfunction, weight gain

Can generally be given once a dayCan generally be given once a day Concern about increasing suicidal Concern about increasing suicidal

thinking/behaviorthinking/behavior

Irritability: Aggression, Irritability: Aggression, Self-Injury, Severe Self-Injury, Severe

TantrumsTantrums Typical antipsychoticsTypical antipsychotics Atypical antipsychoticsAtypical antipsychotics Mood stabilizersMood stabilizers Alpha-2 agonistsAlpha-2 agonists NaltrexoneNaltrexone

Irritability (Cont’d)Irritability (Cont’d)

Typical AntipsychoticsTypical Antipsychotics Haloperidol Haloperidol Thioridazine (rare use, sudden Thioridazine (rare use, sudden

death) death) ChlorpromazineChlorpromazine TrifluoperazineTrifluoperazine FluphenazineFluphenazine

Irritability (Cont’d)Irritability (Cont’d)

Typical AntipsychoticsTypical Antipsychotics Side-EffectsSide-Effects

acute extrapyramidal symptoms (EPS), acute extrapyramidal symptoms (EPS), tardive dyskinesia (TD), sedation, weight tardive dyskinesia (TD), sedation, weight gain, droolinggain, drooling

Irritability (Cont’d)Irritability (Cont’d)

Atypical AntipsychoticsAtypical Antipsychotics ClozapineClozapine RisperidoneRisperidone OlanzapineOlanzapine QuetiapineQuetiapine ZiprasidoneZiprasidone AripiprazoleAripiprazole PaliperidonePaliperidone

ClozapineClozapine

Common side effects include weight Common side effects include weight gain, sedation, droolinggain, sedation, drooling

Can lower the seizure thresholdCan lower the seizure threshold Agranulocytosis and need for careful Agranulocytosis and need for careful

blood monitoringblood monitoring

RisperidoneRisperidone

Well-studied in autism (FDA Well-studied in autism (FDA approval) and mental retardation approval) and mental retardation associated with behavioral associated with behavioral dyscontroldyscontrol

Common side effects: weight gain, Common side effects: weight gain, sedation (transient), drooling, sedation (transient), drooling, elevated prolactinelevated prolactin

OlanzapineOlanzapine

Only small controlled studies in Only small controlled studies in developmental disabilitiesdevelopmental disabilities

Common side effects: weight gain Common side effects: weight gain (at times significant), has been (at times significant), has been associated with glucose and lipid associated with glucose and lipid dysregulation, sedationdysregulation, sedation

QuetiapineQuetiapine

No controlled studies in No controlled studies in developmental disabilitiesdevelopmental disabilities

Common side effects: weight gain Common side effects: weight gain (may be less prominent than with (may be less prominent than with clozapine and olanzapine), sedation, clozapine and olanzapine), sedation, orthostatic hypotension if dose orthostatic hypotension if dose increased too quicklyincreased too quickly

ZiprasidoneZiprasidone

No controlled studies in No controlled studies in developmental disabilitiesdevelopmental disabilities

Common side effects: sedation Common side effects: sedation (transient), occasional insomnia or (transient), occasional insomnia or behavioral activation. Not associated behavioral activation. Not associated with significant weight gainwith significant weight gain

Should not be given to patients with Should not be given to patients with cardiac problemscardiac problems

AripiprazoleAripiprazole

Positive controlled study in youth Positive controlled study in youth with autism spectrum disorderswith autism spectrum disorders

Common side effects: EPS and Common side effects: EPS and nausea/vomiting if given at too high a nausea/vomiting if given at too high a starting dose. Akathisia. Occasionally starting dose. Akathisia. Occasionally transient sedation or activation. Not transient sedation or activation. Not associated with significant weight associated with significant weight gain or prolactin elevationgain or prolactin elevation

PaliperidonePaliperidone

Major active metabolite of Major active metabolite of risperidonerisperidone

Potentially fewer drug-drug Potentially fewer drug-drug interactionsinteractions

Once daily dosingOnce daily dosing Potentially less weight gain and Potentially less weight gain and

prolactin elevationprolactin elevation

Irritability (Cont’d)Irritability (Cont’d)

Mood StabilizersMood Stabilizers Valproic acidValproic acid LithiumLithium CarbamazepineCarbamazepine GabapentinGabapentin TopiramateTopiramate OxcarbazapineOxcarbazapine

Valproic AcidValproic Acid

The only controlled study in autism found The only controlled study in autism found no drug vs. placebo differenceno drug vs. placebo difference

Common side effects: sedation, weight Common side effects: sedation, weight gaingain

Need to monitor blood level for Need to monitor blood level for therapeutic range and to follow liver therapeutic range and to follow liver function testsfunction tests

May be useful in patients with seizures May be useful in patients with seizures and aggressionand aggression

LithiumLithium

No controlled studies in No controlled studies in developmental disabilitiesdevelopmental disabilities

Common side effects: tremor, Common side effects: tremor, polydipsia, polyuria, weight gainpolydipsia, polyuria, weight gain

Need to monitor blood for Need to monitor blood for therapeutic range and to follow therapeutic range and to follow kidney and thyroid functionkidney and thyroid function

CarbamazepineCarbamazepine

No controlled studies in No controlled studies in developmental disabilitiesdevelopmental disabilities

Common side effects: dizzinessCommon side effects: dizziness Need to monitor blood level for Need to monitor blood level for

therapeutic range and to follow blood therapeutic range and to follow blood count and sodium levelcount and sodium level

OxcarbazepineOxcarbazepine

Not well studied in developmental Not well studied in developmental disabilitiesdisabilities

Negative study in adolescent bipolar Negative study in adolescent bipolar disorderdisorder

Need to monitor serum sodiumNeed to monitor serum sodium

GabapentinGabapentin

No controlled studies in No controlled studies in developmental disabilitiesdevelopmental disabilities

Common side effects: some Common side effects: some sedation, some weight gainsedation, some weight gain

No need to monitor blood levelsNo need to monitor blood levels Not particularly effective on a clinical Not particularly effective on a clinical

basisbasis

TopiramateTopiramate

No controlled studies in No controlled studies in developmental disabilitiesdevelopmental disabilities

Common side effects: sedation, Common side effects: sedation, cognitive dulling. Not associated cognitive dulling. Not associated with weight gainwith weight gain

No need to monitor blood levelsNo need to monitor blood levels

Irritability (Cont’d)Irritability (Cont’d)

Alpha-2 AgonistsAlpha-2 Agonists Guanfacine: not particularly Guanfacine: not particularly

effective for aggressioneffective for aggression Clonidine: can be effective for Clonidine: can be effective for

aggression. Need to balance aggression. Need to balance sedation vs. clinical benefitsedation vs. clinical benefit

Need to monitor blood pressure and Need to monitor blood pressure and heart rateheart rate

Irritability (Cont’d)Irritability (Cont’d)

NaltrexoneNaltrexone Not effective on a clinical basisNot effective on a clinical basis No significant side effects, except:No significant side effects, except: Need to monitor liver functionNeed to monitor liver function

Irritability: ConclusionIrritability: Conclusion

Best evidence based treatments in Best evidence based treatments in persons with developmental persons with developmental disabilities:disabilities: RisperidoneRisperidone AripiprazoleAripiprazole

Mood - DepressionMood - Depression

SSRIs: fluoxetine, paroxetine, SSRIs: fluoxetine, paroxetine, citalopram, escitalopram, citalopram, escitalopram, fluvoxamine etc.fluvoxamine etc.

BupropionBupropion SNRIS: Venlafaxine (elevated blood SNRIS: Venlafaxine (elevated blood

pressure), duloxetinepressure), duloxetine Mirtazapine (weight gain, sedation)Mirtazapine (weight gain, sedation) Tricyclic antidepressantsTricyclic antidepressants

Mood – Bipolar DisorderMood – Bipolar Disorder

Valproic acidValproic acid LithiumLithium CarbamazepineCarbamazepine GabapentinGabapentin TopiramateTopiramate Lamotrigine (Steven’s Johnson Lamotrigine (Steven’s Johnson

Syndrome)Syndrome)

AnxietyAnxiety

SSRIs/SNRIs generally most effectiveSSRIs/SNRIs generally most effective Cautious use/avoid benzodiazepinesCautious use/avoid benzodiazepines

Lorazepam, alprazolam, clonazepam, Lorazepam, alprazolam, clonazepam, diazepam etc.diazepam etc.

AnxietyAnxiety

Buspirone: few side-effects combined Buspirone: few side-effects combined with limited benefitwith limited benefit

Consider mirtazapine (dosed at Consider mirtazapine (dosed at bedtime)bedtime) Commonly associated with sedation and Commonly associated with sedation and

increased appetiteincreased appetite

Sleep Disturbance - Sleep Disturbance - InsomniaInsomnia

Diphenhydramine (paradoxical rxt’n)Diphenhydramine (paradoxical rxt’n) ClonidineClonidine Trazodone (priapism)Trazodone (priapism) Chloral hydrateChloral hydrate Benzodiazepines (paradoxical rxt’n)Benzodiazepines (paradoxical rxt’n) MelatoninMelatonin MirtazapineMirtazapine

PicaPica

SSRIsSSRIs AntipsychoticsAntipsychotics Behavioral strategiesBehavioral strategies

All strategies may hinge on framing All strategies may hinge on framing what drives pica: what drives pica: anxiety/impulsivity/something anxiety/impulsivity/something else/unknownelse/unknown

Inappropriate Sexual Inappropriate Sexual BehaviorBehavior

SSRIsSSRIs Hormonal strategiesHormonal strategies Behavioral strategiesBehavioral strategies

PRN MedicationsPRN Medications

““As needed” drugsAs needed” drugs ““Chemical restraints”Chemical restraints” Common in mental health outside of Common in mental health outside of

MR/DD worldMR/DD world Beta blockers for social anxietyBeta blockers for social anxiety Benzodiazepines and hydroxyzine for Benzodiazepines and hydroxyzine for

anxiety/panicanxiety/panic Antipsychotics for agitation associated with Antipsychotics for agitation associated with

psychotic and bipolar illnesspsychotic and bipolar illness

PRN MedicationsPRN Medications

Acute Inpatient Psychiatry UnitsAcute Inpatient Psychiatry Units About 50% of all inpatients receive at About 50% of all inpatients receive at

least one PRN medication during course least one PRN medication during course of hospital stayof hospital stay

Most frequently antipsychotics and/or Most frequently antipsychotics and/or benzodiazepinesbenzodiazepines

Classic PRN combo for agitation: 5mg Classic PRN combo for agitation: 5mg haloperidol + 2mg lorazepam IMhaloperidol + 2mg lorazepam IM

Usher K, Luck L. Psychotropic PRN: a model for best practice management of acute psychotic behavioural

disturbance in inpatient psychiatric settings. J Ment Health Nurs. 2004 Mar;13(1):18-21

PRN MedicationsPRN Medications

Long-term state psychiatric facilitiesLong-term state psychiatric facilities In one study, 23% of residents received In one study, 23% of residents received

at least one PRN medication in last at least one PRN medication in last monthmonth

Craig TJ, Bracken J. An epidemiologic study of prn/stat medication use in a state

psychiatric hospital. Ann Clin Psychiatry 1995 Jun;7(2):57-64

PRN MedicationsPRN Medications

Nursing homesNursing homes 35% of all psychotropic drugs prescribed 35% of all psychotropic drugs prescribed

for PRN usefor PRN use

Stokes J.A.; Purdie D.M.; Roberts M.S. Factors influencing PRN medication use in nursing homes.

Pharmacy World and Science, Volume 26, Number 3, June 2004 , pp. 148-154(7)

PRN MedicationsPRN Medications

Supervised living environmentsSupervised living environments No systematic studies look at % of No systematic studies look at % of

patients with PRN orders?patients with PRN orders? Clinically we see minority of patients Clinically we see minority of patients

with behavioral PRNswith behavioral PRNs

PRN Medications PRN Medications

Issues:Issues: Chronic, frequent use: If you need it all Chronic, frequent use: If you need it all

the time is it really a PRN?the time is it really a PRN? Who makes the call: Who/Whom are the Who makes the call: Who/Whom are the

appropriate personnel to decide if PRN appropriate personnel to decide if PRN needed?needed?

PRN MedicationsPRN Medications

Issues Continued:Issues Continued: Aren’t you just sedating someone?Aren’t you just sedating someone? Risk of falls/hypotension/dystonic Risk of falls/hypotension/dystonic

reaction/disinhibition: ie side effects.reaction/disinhibition: ie side effects.

PRN MedicationsPRN Medications

Maybe best if narrowly definedMaybe best if narrowly defined PRN use prior to long trips or going to PRN use prior to long trips or going to

the doctor’s office/other appointmentsthe doctor’s office/other appointments PRN for sleep if patient still awake after PRN for sleep if patient still awake after

X number of hours/at a certain timeX number of hours/at a certain time

PRN MedicationsPRN Medications

Frequency of administration is keyFrequency of administration is key If not needing it for months and months, If not needing it for months and months,

consider getting rid of itconsider getting rid of it If need it every other day, look at If need it every other day, look at

adjusting scheduled meds/behavioral adjusting scheduled meds/behavioral intervention changes to try and limit intervention changes to try and limit need for PRNneed for PRN

PolypharmacyPolypharmacy

A chronic problem in our patient A chronic problem in our patient populationpopulation

““Layers of drugs”Layers of drugs” A drug gets added with no plans to A drug gets added with no plans to

remove a preexisting agentremove a preexisting agent

PolypharmacyPolypharmacy

Can end up on drugs with opposite Can end up on drugs with opposite effectseffects Stimulants and benzodiazepines: Stimulants and benzodiazepines:

“Uppers and downers”“Uppers and downers”

PolypharmacyPolypharmacy

In our clinic most commonly seen In our clinic most commonly seen with borderline personality disorderwith borderline personality disorder May be do to fluctuating moods, severity May be do to fluctuating moods, severity

of agitation, anxiety, psychotic-like of agitation, anxiety, psychotic-like phenomenaphenomena

Can almost read a med list and predict Can almost read a med list and predict the diagnosisthe diagnosis

Antipsychotics, plus antidepressants, plus Antipsychotics, plus antidepressants, plus benzodiazepines, plus maybe a stimulantbenzodiazepines, plus maybe a stimulant

PolypharmacyPolypharmacy

How To AvoidHow To Avoid Target Symptom ApproachTarget Symptom Approach

Be sure each drug has defined target Be sure each drug has defined target symptom(s)symptom(s)

If a drug does not adequately treat a target If a drug does not adequately treat a target symptom, discontinue itsymptom, discontinue it

If adding a drug, always consider what the If adding a drug, always consider what the new drug could replacenew drug could replace

PolypharmacyPolypharmacy

Cross-titrationCross-titration Slowly increasing a new drug while Slowly increasing a new drug while

slowly decreasing the drug it replacesslowly decreasing the drug it replaces May takes weeks to a few months, but can May takes weeks to a few months, but can

in some cases be much fasterin some cases be much faster Goal is to not exacerbate Goal is to not exacerbate

behavior/symptoms in the processbehavior/symptoms in the process

Medication DiscontinuationMedication Discontinuation

Goal is least number of drugs at Goal is least number of drugs at lowest doseslowest doses

Medication DiscontinuationMedication Discontinuation

Need behavioral/symptom stability Need behavioral/symptom stability before slowly removing effective before slowly removing effective agentsagents Like to see at least 6-12 months of good Like to see at least 6-12 months of good

symptom control before removing slowly symptom control before removing slowly a effective druga effective drug

Medication DiscontinuationMedication Discontinuation

Good plan to at least try slow med Good plan to at least try slow med reduction, especially if significant reduction, especially if significant side-effects are at risk/developingside-effects are at risk/developing Worst case is behavior worsens and Worst case is behavior worsens and

dose need be restoreddose need be restored Do run risk that behavioral control will Do run risk that behavioral control will

not be duplicated when dose restorednot be duplicated when dose restored

VignettesVignettes 13 year old male with autistic disorder, IQ=5013 year old male with autistic disorder, IQ=50 Reported failures/lack of significant response of/from Reported failures/lack of significant response of/from

aripiprazole, risperidone, quetiapine, guanfacine, Adderallaripiprazole, risperidone, quetiapine, guanfacine, Adderall BMI at >99% for age and genderBMI at >99% for age and gender Gained weight on all antipsychoticsGained weight on all antipsychotics Also on Concerta 54mg, trazodone 50mg for sleep and Also on Concerta 54mg, trazodone 50mg for sleep and

quetiapine 200mg TID which is viewed as partially effectivequetiapine 200mg TID which is viewed as partially effective Admitted with increased physical aggression- grabs, hits, Admitted with increased physical aggression- grabs, hits,

spitsspits Sleep OK, no major medical issuesSleep OK, no major medical issues

VignettesVignettes 4 year old with autism, non verbal, 4 year old with autism, non verbal,

intense hyperactivity, aggression and intense hyperactivity, aggression and tantrums in developmental preschooltantrums in developmental preschool

BMI at 50% for ageBMI at 50% for age No major medical problems, no previous No major medical problems, no previous

medicationsmedications

VignettesVignettes 14 year old with ASD, IQ 80, intensely 14 year old with ASD, IQ 80, intensely

fears fire drills, has outbursts going to fears fire drills, has outbursts going to school, attacks parents on school days, school, attacks parents on school days, emesis in the morning at school, no emesis in the morning at school, no medical problemsmedical problems

Recently started aripiprazole 5mg daily, Recently started aripiprazole 5mg daily, 50% reduction in agitation, but still 50% reduction in agitation, but still missing 2 days of school per weekmissing 2 days of school per week

VignettesVignettes 7 year with ASD, intermittent agitation controlled 7 year with ASD, intermittent agitation controlled

on risperidone, admitted due to running away on risperidone, admitted due to running away from school in the street, hyperkinetic, cannot sit from school in the street, hyperkinetic, cannot sit still, unable to stay in seat at schoolstill, unable to stay in seat at school

Current medication: risperidone .5mg BID, Current medication: risperidone .5mg BID, clonidine .2mg HS for sleep, melatonin 3mg QHS clonidine .2mg HS for sleep, melatonin 3mg QHS for sleepfor sleep

Previous medication trials: daytime clonidine too Previous medication trials: daytime clonidine too sedating, guanfacine non helpfulsedating, guanfacine non helpful

Unable to swallow pillsUnable to swallow pills

VignettesVignettes Age 12, ASD, explosive aggression, history of Age 12, ASD, explosive aggression, history of

abnormal EEG, never treated for frank abnormal EEG, never treated for frank epilepsyepilepsy

No other medical problems, BMI 50% for age. No other medical problems, BMI 50% for age. Current meds: naltrexone, lithium, Current meds: naltrexone, lithium,

risperidone, clonidine .1mg TID and .2mg HSrisperidone, clonidine .1mg TID and .2mg HS Past med failures: quetiapine, aripiprazole, Past med failures: quetiapine, aripiprazole,

guanfacine, olanzapine, haloperidol, guanfacine, olanzapine, haloperidol, fluoxetine, clonazepamfluoxetine, clonazepam

VignettesVignettes Age 16, ASD, severe self-injury, history of retinal Age 16, ASD, severe self-injury, history of retinal

detachments, seizure disorder- last seizure 18 detachments, seizure disorder- last seizure 18 months ago, stable on valproic acidmonths ago, stable on valproic acid

Current meds: haloperidol 10mg TID, trazodone Current meds: haloperidol 10mg TID, trazodone 150mg HS for sleep, Depakote ER 1000mg BID, 150mg HS for sleep, Depakote ER 1000mg BID, guanfacine 1mg TIDguanfacine 1mg TID

BMI 50%, no other medical issues other than epilepsyBMI 50%, no other medical issues other than epilepsy Previous medication failures: aripiprazole, Previous medication failures: aripiprazole,

risperidone, quetiapine, olanzapine, chlorpromazine; risperidone, quetiapine, olanzapine, chlorpromazine; was on aripiprazole and risperidone at same time was on aripiprazole and risperidone at same time beforebefore

VignettesVignettes 17 year old developmental disability, no ASD, FAS, 17 year old developmental disability, no ASD, FAS,

history of physical and sexual abusehistory of physical and sexual abuse Intermittent about 3 times per week major aggression, Intermittent about 3 times per week major aggression,

mainly towards mothermainly towards mother Admitted 4 times in last 12 monthsAdmitted 4 times in last 12 months Failed aripiprazole, risperidone, olanzapine, ziprasidone, Failed aripiprazole, risperidone, olanzapine, ziprasidone,

guanfacineguanfacine Current meds: Quetiapine 300mg BID, minimally Current meds: Quetiapine 300mg BID, minimally

effective; clondine .2mg HS for sleep, fluoxetine 20mg effective; clondine .2mg HS for sleep, fluoxetine 20mg daily for history of anxietydaily for history of anxiety

BMI 25% for age, no medical problemsBMI 25% for age, no medical problems

VignettesVignettes 17 year old developmental disability, no ASD, FAS, 17 year old developmental disability, no ASD, FAS,

history of physical and sexual abusehistory of physical and sexual abuse Intermittent about 3 times per week major aggression, Intermittent about 3 times per week major aggression,

mainly towards mothermainly towards mother Admitted 4 times in last 12 monthsAdmitted 4 times in last 12 months Failed aripiprazole, risperidone, olanzapine, ziprasidone, Failed aripiprazole, risperidone, olanzapine, ziprasidone,

guanfacineguanfacine Current meds: Quetiapine 300mg BID, minimally Current meds: Quetiapine 300mg BID, minimally

effective; clondine .2mg HS for sleep, fluoxetine 20mg effective; clondine .2mg HS for sleep, fluoxetine 20mg daily for history of anxietydaily for history of anxiety

BMI 25% for age, no medical problemsBMI 25% for age, no medical problems

VignettesVignettes 15 year old with ASD, IQ 125, admitted 15 year old with ASD, IQ 125, admitted

with self-inflicted chest inflicted chest with self-inflicted chest inflicted chest laceration from knife, bullied at school, laceration from knife, bullied at school, suicidal ideation for six months, suicidal ideation for six months, insomnia, has lost 15 pounds in six insomnia, has lost 15 pounds in six monthsmonths

No medication now or in the pastNo medication now or in the past

QUESTIONS?QUESTIONS?

Craig.erickson@cchmc.Craig.erickson@cchmc.orgorg