Focused?
Front Line Management of Behavioral Health Conditions
Joshua D. Feder MD, Director of Research, Interdisciplinary Council on Developmental and Learning Disorders Associate Professor, Voluntary, Department of Psychiatry UCSD School of Medicine
Disclosures, Fall 2103 • Clinical - 50% time, 99% of income • SymPlay –ipad/ UCI research • ICDL Grad School: math, research • Early Years –peace building • COC – state advocacy for EBP • BRIDGE – 1,.15m in grants • Circlestretch – community resource • Cherry Crisp – media company
Don’t sweat the details - this talk will be posted on‌
The Situation
The Situation • 20% of kids have a behavioral health condition • 1/10th of those get treated • Many symptoms, many diagnoses: Examples: • ADHD + learning disorder + anxiety or mood or oppositional, social difficulties • Autism Spectrum with sensory, motor, mood, learning, perseverative, etc… • Teen with mood, substances, & abuse history
What’s Common • ADHD 5% of kids • Mood disorders 4%, 33% lifetime risk • Autism Spectrum Disorder 2% • Anxiety 1% (+) in kids, more with age • Severe substance issues 1% (+), spike in teens • Etc… Earlier Onsets = Nastier Problems
Areas of Function to Check for Common Psychosocial Problems
‘HEADS’ • Home: relationships, culture & values, abuse • Education: grades, activities, peer issues • Activities: peers, sports, clubs, community • Drugs: and medications, herbals, diets • Sex: identity, exposure, intimacy
Your Possible Roles Assessment: • Medical check, lab studies, & referrals • Behavioral symptoms checklists – DSM 5 • What the child tells you, shows you • Time to talk to family, teachers, etc. Management: • Supporting the child in the office & beyond • Continuing medication for a stable patient • When to ask for help
Assessment • Bio – physical, maybe labs • Psycho – look at symptoms… • Social – home, school, activities
Humiliation is Damaging
Make other time to talk
Make time – Save Time*
*You get important information for treatment. Bonus: Specific plans for follow up calls and appointments reduce family anxiety
Getting kids to talk • Front load time - pays off later • Stay calm, then they are more calm • Some tell all, some never talk – don’t force it • Statements may work better than questions • ‘So I hear you’ve been upset.’ • ‘We can figure this out’ • Body language – try to read their cues – ask parents! • Some have strong feelings but don’t show them Avoid talking about kids with parents in front of the child or teen - call before or after if necessary
Eye level, stay calm, give some time
In Office Therapy? Help set up “try, & try again” Goal: repair connections with others, over and over to build competence, confidence, & resilience • Take time and listen - take their word for it • Get their ideas: ‘Tell me what you think might help’ • Set up check in over and over* to try other things • Resources – online ideas, etc. *with you, parent, teacher, coach, therapist, mentor, etc.
Relationships matter!
We’ll win some, and we’ll lose some That’s ok - let’s keep trying
Management • Bio – exercise, maybe meds, maybe labs • Psycho – building better problem solving • Social – home, school, activities Adult presence is key: balanced mix of support and expectations is critical to a good outcome
Medication:
Can support a good plan, Can’t make up for a bad plan
• Complete workup: consider (24 hour) EEG, labs, etc. along with complete history, physical, time with the child and family, and collateral information from school, therapists, etc.
• Diagnosis: a hypothesis meant to focus treatment, as well as other possible & co-occurring diagnoses. The 5 axis system helps, and new dimensional axes may work better
• Grid and prioritize target symptoms and possible treatments and fill in likely +’s & -’s, in a flexible decision matrix
• Availability - provider MUST stay in touch with family and school GOLDEN RULE: think carefully before rapid, large changes in dose or before changing more than one thing at a time.
How Do We Decide What to Do? Evidence Based Practice
• From Sackett 1996 to American Academy of Sciences Institute of Medicine 2001 to Buysee 2006 (IMH), and through to today (Brandt, Deil, Feder, Lillas 2013) • The combination of relevant research with clinical judgment and experience to provide families with the information to make truly informed consent decisions based on their own family culture and values.
Balanced thinking: • Too much reliance on a research paper might not make sense (teaching to point to colored squares), or might not be appropriate for family (e.g. separation of child from parent) • Too much reliance on clinical experience alone might lead to use of ineffective approaches and poor results (e.g. ‘wait and see’ for toddlers at risk for disorders of relating and communicating, overuse of antibiotics for ear infections)
Name Your Symptoms… • • • • • • • • • • • • • • • • • • • • •
Activity, impulsivity Anger Attention Anxiety, specific fears Cognition Depression Eating Elimination GI Distress Mood instability, irritability, aggression Motor tone Motor Planning O/C, rigidity Perseverative Pain Reciprocal interaction Seizures Sensory Sensitivity & Processing Sleep Tics Trauma s/s Others??
Targets
Stimulants
+/-
+/-
A C De Mood Mo O/C Rec Sen n o pr Instab tor , ipr sor x g es ility Pla rigi oca y GRIDDING OUT TARGET SYMPTOMS VS. POSSIBLE TREATMENTS i DEVELOPMENTAL n si AND“aggr nni dity l ASDs) Sen FOR LEARNING DISORDERS (INCLUDING e it on ession ng Per inte siti t i ” sev ract vity y o era ion n tive +/- +/+? -
SSRIs
-
-
+/-
-/+
+?
-/+
Neuroleptics
+?
-?
+
-/+
+?
++?
AEDs
+?
-/+
+
-/ +?
+?
Steroids
-?
-?
+?
+?
Central Alpha Agonists
+?
+?
+?
-/+
Etc… LIST OTHER TREATMENTS!
Ac tiv ity
At te nti on
T i c s
-
S l e e p
E t c …
Com ment s
-
Wt Ht tics
-/+
Wt, Ht Sz
+?
+?
-
+?
++??
+?
+
+
Wt. Sz TD NMS
++?
-?
+?
+?
+?
+?
+/-
Mult. SE…
-/+
-?
+?
-?
++?
-?
+?
-?
Mult SE…
+/-
1/+?
-/+?
+?
+?
+?
+?
+
Sleep BP
Medication Impact
• Support regulation and co-regulation by treating, e.g., impulsivity, inattention, anxiety, rigid thinking, perseveration.
• Widen tolerance of emotions so the person is less likely to become overwhelmed.
• Treat co-occurring conditions, e.g., depression in ADHD, irritability in ASD.
• Might promote abstract reasoning and thinking.
Stimulants • • • •
• • •
Methylphenidate: Ritalin, Concerta, Metadate, Methylin, Focalin, Daytrana Patch, Quillivant liquid Dextroamphetamine: Adderall, ‘mixed salts’, Vyvanse Slightly different mechanisms. Similar possible side effects: appetite, sleep, withdrawal, depressed mood, unstable mood, tics, obsessiveness, etc. Get a cardiac history, maybe an EKG. Drug diversion vs. drug abuse risk ‘ADHD’ and ASD Often makes a good plan workable.
SSRIs • One of many classes of ‘antidepressants’ • Can really help depressed mood, maybe anxiety, less likely obsessiveness (although works well for that for ‘neurotypicals’) • Prozac (fluoxteine), Zoloft (sertraline), Paxil (paroxetine), Luvox (fluvoxamine), Celexa & Lexapro (citalopram). • Similar possible side effects: ‘behavioral activation’, weight gain (and loss), mood instability, lower seizure threshold, etc. • Drug-Drug interactions & Serotonin Syndrome – sweating is often the first sign • Black box warning misleading: suicide rate had been dropping, then the warning in 2004 led to reduced prescriptions and higher rates of suicide.
Neuroleptics • Zyprexa (olanzapine), Risperdal (risperidone), Abilify (aripiprizole), Seroquel (quetiapine), Geodan (ziprasidone), Haldol (haloperidol), Mellaril (thioridizine), Thorazine (chlorpromazine) and others. • Discovered while looking for cold pills, developed for symptoms of psychosis. • Helping aggression, mood stability, and miracles? As well as tics, and adjunct for depression, perseveration, etc.? • Monitor weight ,fasting lipids, and fasting glucose, as well as for seizures, fevers (NMS) and new abnormal movements (TD), stroke (elderly), cardiac • Should we always consider neuroleptics in ASD?
Abnormal Involuntar y Movement Scale (AIMS)
AEDs • Anti-Epileptic Drugs (aka anti-seizure medications) • So many and all so different in character • For seizures, and for mood stabilization • Many kids on the spectrum have seizures! • Might help other medications work better (stimulants, antidepressants) • Combined pharmacology vs. polypharmacy • Sudden stopping might make seizures more likely
Specific AEDs • Depakote (valproic acid, valproate) – pretty reliable, easy to load, watch levels, platelets, bruising, liver, pancreas, carnitine, menstrual irregularities, weight, sedation. Problems when using with Lamictal • Tegretol (carbemazepine) - ?reliable, watch levels, blood counts, EKG, lots of drug interactions, induction of hepatic enzymes, weight gain, sedation, rash • Trileptal (oxycarbezepine) – ‘Tegretol light’?; motor problems, electrolyte issues, rash?
More AEDs • Keppra (levetiricetum) – easy to use, but does it work? • Lamictal (lamotragine) – mood stability, ?better mood. Must go slow, and watch for rash – Stevens Johnson Syndrome • Topamax (topiramate) – adjunct, may cause weight loss, loss of expressive language, usually need to go slow. May be useful for addiction, Tourettes, OCD. • Neurontin (gabapentin) – Does it work at all? Does it harm at all? Does help pain syndromes, maybe anxiety too. • Lyrica (pregabalin) – for pain in fibromyalgia, partial seizures • Zarontin (ethosuccimide) – for partial/ absence seizures; liver issues
Central Alpha Agonists • Tenex & Intuniv (guanfacine), Catapres (clonidine) • Reducing ‘fight – flight’ sympathetic tone, which can help in many ways • Vigilance theory • Side effects can include sedation, dizziness, early tolerance • Mild medicine • Maybe get an EKG for clonidine?
Other Commonly Considered Medications… • Straterra (atamoxetine) – for ADHD; may be as good as placebo, may act like an antidepressant (+/-) • Wellbutrin (bupropion, etc.) – dopaminergic, weight, loss, sleep loss, irritability, seizure risk, headache risk • Rozerem (ramelteon) – melatonin agonist • SNRIs – Effexor (venlafaxine), Cymbalta (duloxetine), Remeron (mirtazepine), Serzone (nefazedone), Pristique (desvenlafaxine). Watch for withdrawal. • Deseryl (trazodone) – antidepressant often used for sleep; cognitive side effects, priapism • Buspar (an azaspirone) – mild, serotonergic cross reactions
More Others… • Lithium – great mood stabilizer; anti-suicidal; bipolarASD connection; levels, thyroid, kidney function; blood levels, NPH (wet, wild & wobbly) • Namenda (memantine) – Alzheimer’s med – ‘antagonist of the N-methylD-aspartic acid (NMDA) glutamate receptor, this drug was hypothesized to potentially modulate learning, block excessive glutamate effects that can include neuroinflammatory activity, and influence neuroglial activity in autism’
Meds I avoid… • Paxil (paroxetine), Effexor (venlafaxine), Cymbalta ( duloxetine) withdrawal • Tegretol (carbemazepine) – hard to make it work • Combo Depakote and Lamictal – levels unwieldy • Tricyclics – Tofranil (imipramine), Norpramin (desipramine), Pamelor (nortriptyline); and, esp. good for typical OCD, Anafranil (clomipramine). Cardiac, blood pressure issues. • Monoamine Oxidase Inhibitors – Nardil (phenelzine) , Parnate (tranylcypromine), Marplan (isocarboxazide), Emsam (selegiline) – can be useful although dietary, blood pressure drop and hypertensive crisis must be considered; lots of drugdrug interactions
Special Caution on Benzodiazepines! • Benzodiazepines – Valium (diazapam), Ativan (lorazepam), Xanax (alprazolam), Klonopin (clonazepam), and others • Used so freely by many doctors and families • Problems nearly always outweigh risks • Addicting • Destabilizing mood • Interfere with learning • Interfere with motor function • Interfere with memory
Usual general guidelines • Start low, go slow • Try not to change more than one thing at a time, including meds, placements, etc. • Give things enough time to work, to work themselves out • Always have a next appointment and a way to stay in touch
Ask for help: • No one should work alone • All suicidal/homicidal ideation is serious • Look for interactions – ask about supplements, etc. • Sweating, ataxia, loss of bladder control • Blood pressure – what’s right for age? • Abuse, unusual boundaries • Treating people you already know
Summary: • Look at the whole picture, take time to think • Be careful with meds • Think ‘repair’ • Never work alone
Your Experiences?