Medication support for dir programs october 28 2011 tel aviv by Circlestretch

Joshua D. Feder, MD October 28, 2011 Tel Aviv, Israel

Redacted for Posting Case material removed ď&#x201A;&#x17E; Questions? email jdfeder@pol.net ď&#x201A;&#x17E;

Director of Research, Graduate School, Interdisciplinary Council on Developmental and Learning Disorders Assistant Clinical Professor, Dept of Psychiatry, University of California at San Diego School of Medicine 3

ICDL Graduate School ICDL Southern California Regional Institute NIMH/ Duke University/Pfizer SymPlay, LLC 4

Feder 411 Math, Engineering, and Developmental Disorders beginning 1978.  US Navy – Child Psychiatry  Mike – 1990 (1992)  Greenspan and Wieder – 1993  Career expansion: clinic, teaching, research, advocacy, tech development and arts & media. 

 The

DIR/Floortime Model  Reflective Process  Support for the DIR Model  Considering medication  Case examples  Your experiences 6

But First, Some Commercials… Because we build ideas together  And you can join us in the effort! 

Working Together for

Parent Choice! 9

The Southern California DIR/Floortime Regional Institute

Pasadena, California February 24-26, 2012 10

Thank You! Families – say a silent thank you  Greenspan & Wieder  Mara Goverman  Daniel Carlat  David Sackett (et. al.)  Ricki Robinson  Michael Chez  So many others… 

Assumptions Varying familiarity with DIR/Floortime and the supporing research. ď&#x201A;&#x17E; Varying understanding of Evidence Based Practice ď&#x201A;&#x17E;

Conclusions: The program is paramount.  Reflective process is the key to a good program.  Medication might help a good progam work better 

Why DIR? because it’s… Broad – whole child, supports family  Welcoming – all about building love  Enriching – closeness brings progress in relating, communicating, and thinking 

Taking Notes?  One

ENGAGEMENT

word:

 Engagement  Connection

goes beyond compliance

before correction

DIR ‘quick guide’ … Developmental - regulation, warm trust, then a flow of enriching interactions  Individual Differences– sensory, motor, communication, visual-spatial, cognitive  Relationship Based – connecting and supporting at many levels 

Quality of Caregiver-Baby Relationship Matters  D.W.

Winnicott

 There is no such thing as a baby……  A baby cannot exist alone, but is essentially part

of a relationship  Relationships

are central to development

Affect = Emotional Connection The “glue” that organizes all of the jobs of the brain  Coordinates the nervous system from the brain outward  Lends purpose and meaning to the information we take in through our senses  Emotional based learning experiences become an internal reinforcement that motivates 

Theory Behind DIR Affect is the central organizer of experience in all developmental domains  Experience is dual coded in the sensory system and the affect cueing system  Individual differences in processing sensory motor information impact how parents and children make meaning from their interactions and from expectations about their relationships 

Individual Differences Sensory modulation and processing  Postural control and motor planning  Receptive communication  Expressive communication  Visual-spatial funciton  Praxis: knowing how to do things to solve the social problem of the moment 

Things to Keep in Mind Hypo-reactive (decreased sensitivity) Sensory seeking Does not register input or has delayed responsiveness to sensory input Hyper-reactive (increased sensitivity) Sensory avoiding Associated with increased reactivity to sensory input (fight/flight/fright responses) Mixed Hypo/Hyper-Sensitivity: common

Caregiver Patterns and Child Development Sensitive responsiveness  Attunement  Mutually confirming interactions 

 Mirroring, Matching, Expanding



Attachment  Secure, Anxious, Avoidant, Chaotic, Aloof

Relationship Classification Overinvolved  Underinvolved  Anxious/Tense  Angry/Hostile  Mixed Relationship Disorder  Abusive (verbal, physical, sexual) 

More to the point: Joint attention – responsive (cured), initiated (when we wait for it)  Intent  Engagement  Repair (Tronick) 

These are at the core of the moment to moment affective reciprocity that supports the developing relationship. 27

Functional Emotional Developmental Levels I

co-regulation, ability to attend, interest in the world

engagement, attachment, gleam in the eye, warmth

III

circles of interaction, purposive two way communication

flow, social problem solving, behavior organization

symbolic thinking (critical shift)

logical connections between ideas (what, when, how, and why questions)

VII

multicausal thinking

VIII grey area thinking IX

reflective thinking, stable sense of self, and an internal standard

I - Calm enough: (Co-regulation)  Know

the person: individual differences  We do this together –  Not a ‘sensory break’ (= escape)  Reach wth 80% intensity to help the person calm down with you.  ‘Calm enough’ might mean active enough.  Think about what works and what doesn’t work

II - Truly Connected to Others (Engagement) That gleam in the eye…  Mostly fun and feels good for everyone  creates the bond that will leads to learning  Joint attention, but joyful 

III – Circles: back and forth interaction The

person is always doing something

Follow

the child’s lead - Join in - be part of the activity Improv = ‘yes’ If you can’t just join in, gently and playfully get in the way If

he wants something, he has to get it from you

IV – Flow

(and avoiding questions) Chains of 20-40 circles  Expanding complextiy  Questions make people close up or act mad  Statements create social ‘problems’ that the other person can ‘solve’  Try it out. It’s hard, but worth the work 

Things to Avoid 

Don’t just entertain, quiz, or direct the child with your games, demands, or ideas



Don’t merely follow the child around – use the child ‘lead’ to start off



Every idea is a good one to play with – don’t say ‘no’ to the idea - connect and play with it. You can set limits as needed.

What about other kids? Start with adults  Build some skills  Semi-structured activities with peers  Limiting numbers of kids  Mediate the process – slow it down  Statements more than questions  Democratic decision making 

Things you might say or do: “We need to figure out what to do…”  “I need help with…”  “Wait - I didn’t hear you…”  “We can vote on whether he was out..”  Semi-structured: at times you direct things, but work toward less of it.  In free play, you join the person in a way that attracts other kids, then facilitate the mix 

Likert Scale for Each Level 1. 2. 3. 4. 5. 6. 7.

Not doing it Barely able to do it Islands of time where the child can do it Can expand those islands with our help Comes back for more with little or no support Pretty normal unless under stress Age appropriate

Family /Caregiver Patterns: 

Comforting



Finds appropriate level of stimulation



Engages in relationship



Reads cues and signals



Maintains affective flow (for coregulation)



Encourages development

The Learning Tree

Summary: Why DIR? It is BPS, and BPS is good  We can change outcomes despite genetics.  Affect is the key - this is affect based  Beyond behavioral treatments  Medication can only support treatment  There is Evidenced Based Research to support it 

Research Support for DIR/Floortime Macro: comprehensive interventions Odom, et al. – there is no one ‘winner’.. Care reports, single case studies Salt, Mahoney PLAY Pajareya York Micro: core concepts Joint attention Parent coaching Repair

Evidence based medicine, and informed consent

Reflective Process  There

are always new challenges  Nothing goes as expected  Caregivers rarely have the support and time they need to think  Make time – a moment to listen.

Reflective Process: in the moment  Humility:

you do not have the ‘answer’  Facilitate problem solving  Wonder about the situation  Track the emotion, then and now  Statements vs. questions.  Empowering vs. dictating.

Reflective Process: regular contact  

Selling the idea of making another moment – can we make an appt to check in later? Set another time to check in.

Medications ď&#x201A;&#x17E;

Rationale for using medication: last resort vs. covering all bases

Controversies about medications in developmental and learning disorders: Stimulants  Antidepressants  core symptoms  overmedication 

Specific Medications For details see circlestretch.com ď&#x201A;&#x17E; For a framework, see The Learning Tree (+caregiver profile) ď&#x201A;&#x17E;

Remember the Tree

Individual Differences – Charlie – Preschool 5/05 & Kindergarten 9/05 Sensory

Postural

Response to Communicati on

Intent to Communi cate

Visual Exploration

Praxis -

Sensory seeking, distractible … Auditory Visual Tactile Vestibular Proprioceptive Taste Odor

Low tone; A bit clumsy impedes rapid reciprocity in the moment 1 indicate desires 2. mirror gestures 3. imitate gesture ---- 05/05---4. Imitate with purpose.

Trouble managing more than one thing at a time 1. Orient 2. key tones

Dysarthric – Logical discourse is Difficult 1. Mirror vocalizations 2.. Mirror gestures 3. gestures 4. sounds 5.Words ---- 05/05--6. two –word

Distractible. 1.focus on object ---- 05/05---2. Alternate gaze 3. Follow another’s gaze to determine intent. 3. Switch visual attention 4. visual figure ground 5. search for object 6. search two areas of room

Easily frustrated Ideation -- 05/05--Planning (including sensory knowledge to do this)

5. Obtain desires 6. interact: - exploration - purposeful -self help -interactions

3. key gestures 4. key words ---- 05/05---5. Switch auditory attention back and forth 6. Follow directions 7. Understand W ?’s 8.abstract conversation.

7. Sentences 8. logical flow.

Sequencing Execution Adaptation

7. assess space, shape and materials. -

Individual Differences – Charley – First Grade Sensory

Postural

Response to Communicati on

Intent to Communi cate

Visual Exploration

Praxis -

Sensory seeking, distractible … Auditory Visual Tactile Vestibular Proprioceptive Taste Odor

Low tone; A bit clumsy impedes rapid reciprocity in the moment 1 indicate desires 2. mirror gestures 3. imitate gesture 4. Imitate with purpose. ----3/07---5. Obtain desires 6. interact: - exploration - purposeful -self help

Trouble managing more than one thing at a time 1. Orient 2. key tones

Dysarthric – Logical discourse is Difficult 1. Mirror vocalizations 2.. Mirror gestures 3. gestures 4. sounds 5.words ----3/07---6. two –word

Distractible. 1.focus on object 2.----3/07---2. Alternate gaze 3. Follow another’s gaze to determine intent. 3. Switch visual attention 4. visual figure ground 5. search for object 6. search two areas of room

Easily frustrated Ideation

Taste and odor are better

3. key gestures 4. key words ----3/07---5. Switch auditory attention back and forth 6. Follow directions 7. Understand W ?’s 8.abstract conversation.

-interactions Much better postural control – Stronger not flopping on foundation floor

7. Sentences 8. logical flow. NOT CHANGED

Planning (including sensory knowledge to do this) ----3/07---Sequencing Execution Adaptation

7. assess space, shape and materials.

A step forward..

Can focus pretty well on an object now

Sample Full FEDL (Charlie) Not there

Barely

Islands

Expands

Comes back

Co-regulate

3/06

3/07

3/08

3/09

Engage

3/06

3/07

3/08

3/09

Circles

3/06, 3/07

3/08

3/09

Flow

3/06

3/07

3/08, 3/09

Symbolic

3/06

3/07, 3/08

3/09

Logical

3/06

3/07, 3/08

3/09

Multicausal

3/06, 3/07

3/08

3/09

Grey area

3/06, 3/07,

3/08, 3/09

Reflective

3/06, 3/07

3/08, 3/09

Ok if not stressed

Ok for age

Relationships - Caregiver Profiles: Not yet able to support

Just starting to support

Islands of support

Moderately effective in supporting ’50%’

Becoming consistent in ability to support

Effective except when stressed

Very Effective in supporting

Comforting the child Finding appropriate level of stimulation Pleasurably engages the child Reads child’s emotional signals Responds to child’s emotional signals Tends to encourage the child

]

Relationships - Caregiver Profiles: first grade teacher, aide Not yet able to support

Just starting to support

Islands of support

Comforting the child

Not fuzzy, but not reactive

Finding appropriate level of stimulation

directive

Pleasurably engages the child

directive

Reads child’s emotional signals

Sees when he is upset

Responds to child’s emotional signals Tends to encourage the child

Unsure what to do

Moderately effective in supporting ’50%’

Becoming consistent in ability to support

Effective except when stressed

Very Effective in supporting

mellow

unflappable

Persistent attempts to engage him Can predict when he will become upset

Interested in the flow of activity, not interaction

directive

Wants him regulated so he can learn (not interact per se)

Relationships - Caregiver Profiles: second grade teacher, resource teacher, aide Not yet able to support

Just starting to support

Islands of support

Moderately effective in supporting ’50%’

Comforting the child Finding appropriate level of stimulation Pleasurably engages the child

directive

Reads child’s emotional signals Responds to child’s emotional signals

Still unsure what to do

Tends to encourage the child

Still directive

Effective except when stressed

Kind and clear mellow

Really there for him, can help him settle

Pretty good with him

Learning to engage

Predict when he is upset

Becoming consistent in ability to support

Very Effective in supporting

Calm and positive, able to flexibly shift level of stimulation Some nice non-verbal flow

Tries hard to do this in the moment

Naturally reads his cues

Interested in the flow of interaction

Naturally responds

Strong desire to see him regulated and engaged

Regulated for interaction; coaches aides, staff

Medications Approved by the FDA for Marketing for the Treatment of Autism  Risperdal

- 10/06 - Irritability  Abilify - 11/09 – Irritability

Thanks and Have a Good Day!

Ok, there’s more to it… Are medications a good thing?  Medical Ethics  FDA  Evidence Based Medicine  Informed Consent  Family  How Doctors Think  Medications and medication options 

It’s complex… People like things simple and practical  This is not simple  But if you follow along, it can be quite helpful and practical. 

Good Medicine Good = it might help (help what?) beneficence  Good = it won’t cause bad side effects ‘Do No Harm’ – non-maleficence 

4 Main Principles of Medical Ethics* 1. Beneficence

– doing good (Evidence Based Medicine) 2. Non-maleficence – risk vs. benefit (Do No Harm) 3. Autonomy – informed consent without deception 4. Justice – allocation of resources, laws (avoiding aversive practices) *Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 3rd ed. New York, Oxford: Oxford University Press, 1989.

History of Trying to do Good Food and Drug Act of 1906 – safe medicines, not diet pills from tapeworm eggs  Flexner Report on Medical Education 1910 – medical care has risks and so medical education requires standards 

The FDA Approves medication for marketing for specific symptoms of specific conditions ď&#x201A;&#x17E; Allows doctors to use medications for whatever they think is appropriate ď&#x201A;&#x17E;

FDA Approval of a Medicine for Marketing Requires studies showing it works for some symptoms of some condition  Safety studies – now for kids too!  Difficult process  Expensive process 

It’s Especially Hard to Do Studies On Medications in Kids with ASDs Kids are hard to find  Kids have multiple ‘diagnoses’  Kids with ‘Autism’ are a very mixed group 

New approaches:

CAPTN Child & Adolescent Psychiatry Trials Network NIH / Duke  Efficiency Studies  Pharmacogenetics  Results pending 

The upshot, for the moment… Companies seek FDA approval is for BIG MARKETS  Most psychiatric medication for kids is ‘experimental’ 

Doctors Need:  To

know a lot  Respect for trouble  Steady care  Judgment & Experience

Clinical Judgment & Experience with… the condition  the medications  other neurobehavioral and medical conditions  side effects & drug interactions  the terrible things 

Doctor’s Experience Often limited  ‘In my experience’ = seen one  ‘In a series’ = seen two 

Terrible Things… Morbidity – severe side effects (e.g. hepatic failure, NMS, TD, etc. etc.)  Mortality 

Avoiding Trouble Good care: follow up, AIMS, labs, etc.  Laws governing medication  Report medication problems to the FDA  Talk to colleagues  Informed consent: family choice 

Family Choice      

For lifelong challenges Severe symptoms and impact Families must know their options Family circumstances and values are preeminent Hope is essential - unfounded hope is cruel Family choice is the heart informed consent

• • • • • • • • •

Diagnosis Target Symptoms Treatment Protocol Alternative Treatments Results of No Treatment Side Effects FDA Labeling: ‘experimental’ Consent & Assent Comments, Questions & Concerns: ‘track closely’

INFORMED CONSENT IS A PROCESS 75

So why use meds?  Can

help, sometimes dramatically  Duty to Inform

Good information is part of good medical care  Could

help, and perhaps avoid harm  Standard of care  Practice guidelines  ‘Evidence Based Medicine” 77

Evidenced Based Medicine Sackett, et. al. British Medical Journal 1996;312:71-72 (13 January)  “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” 

Meaning… what? integrating clinical expertise with systematic studies  consideration of clinically relevant research  and respect for the individual’s predicament, rights, and preferences 

Misuse of Evidence Based Medicine  Cost

cutters – ‘no research’  Vested Interests – ‘only our research counts’  Convinced Clinicians – ‘my experience is what matters…’

Gold Standard Evidence  Double

Blind  Placebo (or wait list) Controlled  Prospective  Randomized  Multiple Subjects

vs. Medicine Today:  Grave

conditions cannot wait  We work with the data we have  Heterogeneity of populations  Extrapolating from other disorders (OCD), other populations (adults)

And People are Human…  Narrow

thinking  Emotional reasoning  Placebo effects References: How Doctors Think – Groopman; Science and Fiction in Autism – Schreibman; Lies, Damn Lies, and Science – Seethaler 83

So EBM requires:  Current

best evidence  Clinical expertise & judgment

Evidence Changes Over Time –  Half

changes every 5 years  50% is wrong  We don’t which half

 Find

one you can work with  Keep the doctor informed about what is happening with meds and therapy  Don’t overwhelm with data  Doctors can be confused (“biomedical”)  Respectfully offer resources  Good doctor consult other doctors 86

 Competence:

APBN Board

Certified  Ethics: AACAP = try their best

The Role of Medication Overview Progress? A Good Enough Program A General Approach to Medication Gridding the Problem

1989 Magda Campbell: haloperidol helps social learning; others: methylphenidate causes side effects without benefit.  1990’s - 2006: treating target symptoms, based on responses in other conditions to medications; lots of use of neuroleptics for aggression, etc.  2004 Black Box warning for SSRIs in kids  2006 – Risperdal  Early 2009 – Celexa ‘not working’ for OCD in ASD  Late 2009 – Abilify  2010 Cochrane report on SSRI’s and autism 

Most people consider meds because they feel stuck, maybe desperate  Emergencies: aggression, depression, others?  Lack of progress 

• •

What do we want for our children? The usual wish: a meaningful life (socially, emotionally, maybe cognitively)

•

Requires a plan, and medication alone is not a plan.

self regulation, sensory, and motor function  trusting, supportive relationships  communication, maybe language  cognition & learning  living and life skills: home, school, work  compliance with important rules 

Are we asking too much of a child?  Of a family?  Of a school? 

The Central Question ď&#x201A;&#x17E;

Are you trying to improve an appropriate situation or make up for a bad one?

Will they change my child’s brain and fix it?  Could they injure my child?  What should I expect? 

To avoid ‘losing time’ while pulling the program together  To ‘do as much as possible’  Awakenings – are we trying for a miracle? 

 Can’t

guarantee results  If no emergency, there’s time  When parents disagree  Side effects  Treatment teams ‘all about the meds’

 Complete

workup a must: 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 possible treatments and fill in likely +’s & -’s, in a flexible decision matrix  Availability - doctor MUST stay in touch with family and school

and

GOLDEN RULE: think carefully before rapid, large changes in dose or before changing more thing than one thing at a time.

Gridding Target Symptoms

Target symptoms  Prioritizing Symptoms  Core Symptoms 

Name Your Symptoms…

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101

Core Symptoms? Relating Communicating Healthy development: connected, regulated emotions that breathe life into adaptive thinking and planning

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 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.

 Might

promote abstract reasoning and thinking. 103

The Bottom Line: medication probably does not treat core symptoms directly  might make some target symptoms or co-occurring conditions better  creating more affective availability so that we can make progress  if you can avoid significant side effects. 

104

Specific Psychotropic Medications Try to always know the brand and generic names of medications  Rxlist.com is often helpful  The following list and the information provided is not comprehensive; please talk with your own health care provider for further information 

105

Stimulants    

  

Methylphenidate: Ritalin, Concerta, Metadate, Methylin, Focalin Dextroamphetamine: Adderall, ‘mixed salts’, Vyvanse Slightly different mechanisms. Similar possible side effects: appetite, sleep, withdrawal, depressed mood, unstable mood, tics, obsessiveness, etc. Drug diversion vs. drug abuse risk ‘ADHD’ and ASD Often makes a good plan workable. 106

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. Black box warning about suicidal thinking vs. lower rates of actual suicide in people treated with SSRIs

107

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.? Side effects can include weight, lipid, and sugar issues, as well as seizures, fevers (NMS) and new abnormal movements (TD), stroke (elderly), cardiac Should we always consider neuroleptics?

108

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

109

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, weight gain, sedation, rash Trileptal (oxycarbezine) – ‘Tegretol light’?; motor problems, electrolyte issues, rash?

110

More AEDs   

  

Keppra (levetiricetum) – easy to use, but does it work? Lamictal (lamotragine) – mood stability, ?better mood. Must go slow, and watch for rash Topamax (topiramate) – adjunct, may cause weight loss, loss of expressive language, usually need to go slow. Neurontin (gabapentin) – Does it work at all? Does it harm at all? Does help pain syndromes. Lyrica (pregabalin) – for pain in fibromyalgia, partial seizures Zarontin (ethosuccimide) – for partial/ absence seizures; liver issues 111

Steroids    



LKS variant theory – epileptic aphasia – 24 hr EEGs Regression at a young age Cell membrane stabilization in inflammation So many side effects: cushinoid, moon face, hump, central obesity, peripheral wasting, immune compromise, skin striations, mood instability including depression and hypomania Pulsed dosing regimens

112

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 

113

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, seiaure risk Rozerem (ramelteon) – melatonin agonist SNRIs – Effexor (venlafaxine), Cymbalta (duloxetine), Remeron (mirtazepine), Serzone (nefazedone), Pristique (desvenlafaxine). Deseryl (trazodone) – antidepressant often used for sleep; cognitive side effects, priapism Buspar (an azaspirone) – mild, serotonergic cross reactions 114

More Others… 



Lithium – great mood stabilizer; antisuicidal; bipolar-ASD connection; levels, thyroid, kidney function 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’ 115

Meds that I often avoid…    



Paxil (paroxetine), Effexor (venlafaxine), Cymbalta (duloxetine) - withdrawal Tegretol (carbemazepine) – hard to make it work Combo Depakote and Lamictal Tricyclics – Tofranil (imipramine), Norpramin (desipramine), Pamelor (nortriptyline); and, esp. good for typical OCD, Anafranil (clomipramine). Cardiac and 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 drug-drug interactions

116

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

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Getting back to the treeâ&#x20AC;Ś

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Abnormal Involuntary Movement Scale (AIMS)

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Look at the whole picture, and reflect…  Be careful with meds  Engage the Child 

Your Experiences?

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“Never give up, never surrender!” - Captain Peter Quincy Taggart Commander, NSEA Protector