Psychotropic Medication in the Treatment of Developmental and Learning Disorders

8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders

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UCSD RCHSDMarch 24, 2009


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Assistant Clinical Professor,

Dept of Psychiatry, University ofCalifornia at San Diego School ofMedicine

Faculty, Interdisciplinary Council onDevelopmental and Learning

Disorders


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ICDL Faculty minimal - review of

clinical write ups, travel and roomfor summer institute

NIMH/ Duke University minimal

administrative time forpharmacogenetic research


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a novella on the use of medication (20 min)

brief monograph:medication from a DIR perspective (3 min)

fantasies and nightmaresin med-land (2 min)

the story of a real boyand a diagnostic system (20 min)

your stories(15 min)


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all slides will be posted on

circlestretch.blogspot.comfollow the blue dot!


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Quick history: Magda Campbell: haloperidolhelps social learning; others:methylphenidate causes side effects withoutbenefit.

Today: we try to treat target symptoms,carefully, based on responses in otherconditions to medications.

Takes time to assess, and re-assess.Big issues: marketing, side effects, and

efficacy studies.Efficiency study: CAPTN (Duke: John March,

el al Im an et al).


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Most people consider meds becausethey feel stuck, maybe desperateEmergencies: aggression, depression,

others?Lack of progress


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What do we want for the child?What is the meaning of the disability

to the family and to the child?The usual wish: a meaningful life (socially, emotionally, maybe

cognitively)Requires a plan, and medication

alone is not a plan.


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regulatory issues/ motor and sensory areasaddressed

engagement and reciprocity (vs. focus on

compliance) language/ communicationcognition/ learningdaily living skills followed by broader and

broader areas of life skills, from school andplayground to vocational skills.


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Are we asking too much of the child?

Of the family?Of the school?


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Low Support - Low Expectation

(neglect)

Low Support - High Expectation

(Just do it)

High Support - Low Expectation

(walking on eggshells, more andmore constrictede.g. gamers)

High Support - HighExpectation

(respectful coaching)


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Is the program adequate?

Will they change the childs brain andactually fix it?Will they injure the child?

What should I expect?


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Losing time while pulling the programtogetherDoing as much as possibleAwakenings should we go for a

miracle?


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We do not know enough to say you

really should medicateIf there is no emergency, you have

more time to think about it

When parents differ, it can be anopportunity for more thoughtfulplanning


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Are you trying to save a placement or make up for

a bad one? Are meds a last resort or is it unethical to withhold

them? Complete workup a must: consider EEG, labs, etc.

along with complete history, physical, MSE, andcollateral information.

Availability - doctor MUST stay in touch with

family and school Rapid, large, or multiple changes are often

problematic Grid target symptoms vs. possible meds and fill in

possible +s & -s


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Easy for the treatment team to react andoveruse medications

Side effects often create significantdifficulties, e.g., behavioral activation

(SSRIs), increased perseveration(stimulants), sedation (someanticonvulsants, others).

Team treatment often becomes all aboutthe medication, ignoring engagement,

other factors.Bottom line: medication probably does nottreat core symptoms, but might create moreaffective availability, if you can avoidsignificant side effects.


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elements of informed consent

the process of informed consentnearly everything is experimentalwe have to track this fairly closely


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NAME: DOB: DATE:

DIAGNOSIS:TARGET SYMPTOMS:

TREATMENT PROTOCOL:ALTERNATIVE TREATMENTS DISCUSSED:POSSIBLE RESULTS OF NO TREATMENT:SIDE EFFECTS DISCUSSED:

FDA LABELING DISCUSSED:CONSENT AND ASSENT DISCUSSED:COMMENTS/QUESTIONS/CONCERNS:

I UNDERSTAND THIS CONSENT AND ALL HAS BEEN EXPLAINED TO ME. TREATMENT, INCLUDING USEOF MEDICATIONS IS VOLUNTARY AND I PLAN TO WORK WITH THE DOCTOR TO MAKE THE BEST USEOF THESE.

I CONSENT TO THE TREATMENT. IF MEDICATION IS PART OF THE TREATMENT PLAN AND I WILLREQUEST THE PRODUCT INFORMATION INSERT AT THE TIME A PRESCRIPTION IS FILLED.

_____________________ _________ ___________________ PATIENT SIGNATURE DATE PHYSICIAN

_____________________ __________________________ PARENT/GUARDIAN (IF APPLICABLE) RELATIONSHSIP TO PATIENT.

update to plan: date initial of responsible party


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Find a doctor you like and feel you canwork with

Keep the doctor in the loopDont overwhelm the doctor with data

Think carefully before rapid, largechanges in dose or before changingmore thing than one thing at a time.

Respectfully offer resources dont expect

your doctor will read a book for you, but doexpect your doctor is interested in otheropinions from other doctors


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Look for Basic Competence: APBNBoard Certified Child and AdolescentPsychiatrists were checked forcompetence in assessing autism, andfor use of collateral information fromfamily, school, and other

professionals.Look for Honesty: AACAP = a

promise to be ethical and do their

best


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Helping parents determine whenmedication may be worth consideringHelping families navigate well to

utilize their doctors and otherprovidersHelping families orchestrate the

whole set of interventions into acoherent and manageable planGood Luck!


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Can Medications Help Kids HaveBetter,

More Productive RelationshipsWith Us?


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Co-regulationEngagementCirclesFlowSymbolic thinkingLogical social problem solvingMulti-causal thinkingGrey area thinkingReflective thinking, stable sense of self,

internal standard


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Sensory processingPostural control/ motor planningReceptive communicationExpressive communicationVisual-spatial functionPraxis: ideation, planning,

sequencing, execution, adaptation


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Support regulation and co-regulation bytreating symptoms that get in the way,e.g., impulsivity, inattention, anxiety,

rigid thinking, perseveration.Widen tolerance of affective experienceso the person is less likely to becomeoverwhelmed.

Treat co-morbid conditions, e.g.,depression.Possibly: allow for or promote improved

ability for abstract reasoning and

thinking.


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DIR is the main courseMeds are the pickles


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A Good Enough WizardUnpredictable Potions

Nefarious Forces:syndromes & systems(affecting schools, social services, and industry)

and

transferences & countertransferences(invisible and everpresent)


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SeizuresWeight gainInsulin resistanceTardive DyskinesiaNeuroleptic Malignant Syndrome


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perseveration, anxiety, depressionmay improveoften the benefits are outweighed by

overactivity, inattention, or evenmania, rarely seizures, and sweatingas a precursor to serotonin syndrome


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For mood stabilization, oh, and fewer seizures Well Mrs Farkel Liver, pancreas, weight gain,

sedation, incontinence, drooling, and if you everwant to have babies beware of PCOS, loss of whitecells, bleeding problemss

Tegretols blood and cardiac problems Lamictals scathing rash, and unweildy interaction

with Depakote

Topamax: wt loss, but language loss; unreliability,decreased sweatingOthers


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The plan that lived, due to betterfocus and less overactivityRagged sleep, ratty moods, thin waifs

with sunken eyes, stupors, tics, andoccasional paranoia; cardiac andgrowth issues


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Reliable anxiolytic, helpful forseizuresReliable loss of memory and motor

control, with inability to benefit fromlearning and high risk of falling andautomobile accidents

Addiction is rampantALL MEMBERS OF THIS CLASS

(BENZODIAZEPINES) ARE

PROBLEMATIC


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The number one cause of death byantidepressants due to overdose in thedays before SSRIs

CARDIOTOXIC: have people LOCK THEMUP! and get serial EKGs w/ Cardiologistreadings

Still, they are as effective or more effectivethan any other antidepressants we have,and clomipramine is more effective,generally than SSRIs for OCD.


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Find a good enough Wizard, one whoknows the stories, good and bad, andwho listens to you and your people


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case synopsisvideo clipsanalysisdiscussion


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K Searcy - ?Meds for anxiety in

autism, Jan 2008Failure to make gains despitemassive services


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AutismSAFETY fingers in eyesextremely perseverative (fans)

anxietyover-activitytantrums language

hard to take him out, (esp. dad)?seizures.


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planned C/S at 39 wk., mild jaundice, WBC up but ok. constantly nursing, mom w/o sleep. crawled 9 mo, walked 11 mo words at 12 mo but slow to gain new ones and they didnt

stick well

13 mo: sudden stimming, classic ASD,but still cuddling

FH: sister PDDNOS now better, cousin ASD; others:anxiety, OCD

Sp Ed PK and CARES then ACES, Crimson, etc. medical: ?Sz, allergies to eggs, peanuts, amox, eczema

Medicationss: Trileptal, EEG improved;Spring 08 Citalopram at 10 mg helps

anxiety; Fall 08 Metadate CD 15 mg.


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break the door MOV00732.MPG(0:10)Malingo Toya song and dance (0:55)This Little Piggy (4:50)


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Axis I Primary DiagnosisAxis II - Functional Emotional

Developmental Capacities

Axis IIIRegulatorySensory ProcessingCapacities

AxisIVLanguage CapacitiesAxisVVisuospatial Capacities

AxisVIChildCaregiver and Family PatternsAxisVIIStress


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Axis I Primary Diagnosis

Axis II - Functional EmotionalDevelopmental Capacities

Axis IIIRegulatorySensory Processing Capacities AxisIVLanguage Capacities AxisVVisuospatial Capacities AxisVIChildCaregiver and Family Patterns AxisVIIStress


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Notthere

Barely Islands Expands

Comesback

Ok ifnotstressed

Ok forage

Co-regulate

3/08 9/08 3/09

Engage 3/08 9/08 3/09

Circles 3/08 9/08 3/09

Flow 3/08 9/08 3/09

Symbolic 3/08 9/08, 3/09

Logical3/08,3/07,3/08

Multicausal

3/08,3/07,3/08

Grey area 3/08,3/07,3/08

Reflective 3/08,3/07,3/08


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03/08 moments ofgleam and a couple of circleswhen I get playfully in his way unplug the fan orstop him from crawling under my desk

09/08 - join and shift the OC on AC to ram intocouch; shift OC on AC to blanket fan; fishing for feet flow; malingo toya making a song somewhat symbolic

3/09 calmer and able to cuddle nearly the whole session

with mom, makes possible coaching mom for moreelaboration of circles and some flow with her; can talk abouttoes, but not really more symbolic per se.


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Axis I Primary Diagnosis Axis II - Functional Emotional Developmental Capacities

Axis IIIRegulatorySensory

Processing CapacitiesAxis IVLanguage CapacitiesAxis VVisuospatial Capacities AxisVIChildCaregiver and Family Patterns

AxisVIIStress


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Sensory

Postural Response toCommunication

Intent toCommunicate

VisualExploration

Praxis -

Sensory

seeking,distractible

Auditory

Visual

Tactile

Vestibular

Proprio-

ceptive

Taste

Odor

Best when core is

supported

1 indicate desires

----3/08----

2. mirror gestures

3. imitate gesture

4. Imitate withpurpose.

----9/08----5. Obtain desires6. interact:- exploration-purposeful

----3/09----

- self help

-interactions

Cues into important

words

Orient

----3/08----

2. key tones3. key gestures

4. key words

----9/08----5. Switch auditoryattention back andforth6. Follow directions7. Understand W ?s ----3/09----8.abstractconversation.

Often

unintelligible

Mirrorvocalizations ----3/08----

2.. Mirrorgestures

3. gestures

4. sounds

5.words----9/08----

6. two word

7. Sentences----3/09----

8. logical flow.

Spots fans at distance;

fingers in eyes; rare

gleam

focus on object

----3/08----

2. Alternate gaze3. Follow

anothers gazeto determineintent.3. Switch visualattention----9/08----4. visual figureground5. search forobject----3/09----

6. search twoareas of room7. assess space,shape andmaterials.

Perseverative

ideas; canexpand w/support

Ideation----3/08----

Planning(including

sensoryknowledge to dothis)----9/08----

Sequencing----3/09----

Execution

Adaptation


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Axis I Primary Diagnosis Axis II - Functional Emotional Developmental Capacities Axis IIIRegulatorySensory Processing Capacities AxisIVLanguage Capacities AxisVVisuospatial Capacities

AxisVIChildCaregiver and FamilyPatternsAxisVIIStress


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Axis I Primary Diagnosis Axis II - Functional Emotional Developmental Capacities Axis IIIRegulatorySensory Processing Capacities AxisIVLanguage Capacities AxisVVisuospatial Capacities AxisVIChildCaregiver and Family Patterns AxisVIIStress


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100. Interactive Disorders 200. Regulatory Sensory Processing Disorders

300. Neurodevelopmental

Disorders of Relating andCommunicating 400. Language Disorders 500. Learning Challenges


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300.1 Type I:Early Symbolic, with Constrictions ; intermittent capacity for attending,relating, reciprocal social interaction, including social problem solving, and beginning use of

meaningful ideasmakesrapid progress in a comprehensive program

300.2 Type II:Purposeful Problem Solving, with Constrictions; as above but only

fleeting social problem solvingtend to make steady, methodicalprogress

300.3 Type III: Intermittantly Engaged and Purposeful; only fleeting attention andengagement, occasional reciprocal social interaction with lots of support slow,

steady progress possible, maybe with gradual use of words or phrases 300.4 Type IV: Aimless and Unpurposful;multiple regressions, maybe more

neurologic challenges, very very slow progress


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Mar 08: we are in a dangerous crisis dysregulatedand perseverative

Sept 08: with meds and direction to the intervention,

he can be entrained into collaborativeinteractionMar 09: we are confident that with coaching

his capacities will expand


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Medication management, and moreGuiding the whole team, once and

twice removed.As the prescribing physician I have

responsibility, accountability, andleverage - they come back


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Will you be careful with the meds?

Will you look at the whole picture?Will you continue to learn and

explore?


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Psychotropic Medication in the Treatment of Developmental and Learning Disorders

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