Medication support for dir school programs 2

Medication Suppor t for DIR School Programs

Joshua D. Feder, MD, DFAPA ICDL Fall Conference 2010 McClean, Virginia

Redacted for Posting Case material removed ď‚ž Questions? email jdfeder@pol.net ď‚ž

Joshua D Feder MD DFAPA Assistant Clinical Professor, Dept of Psychiatry, University of California at San Diego School of Medicine Faculty, Interdisciplinary Council on Developmental and Learning Disorders

Disclosures ICDL Faculty NIMH/ Duke University NIH R21 grant/ San Diego BRIDGE Collaborative

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• Calm enough to interact • Truly connected to others • In a continuous expanding balanced back and forth flow of interaction “Go for that gleam in the eye!” http://www.circlestretch.com

The Southern California DIRŽ/Floortime™ Regional Institute Pasadena, California October 2010- May 2011 Josh Feder, MD jdfeder@pol.net Mona Delahooke, PhD mdelahooke@socal.rr.com

Diane Cullinane, MD diane@pasadenachilddevelopment.org Pat Marquart, MFT patmarquart@aol.com

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

Introduction Assumptions: some familiarity with DIR/Floortime.  The program is paramount.  Reflective process is the key to a good program.  Medication might help a good plan work 

DIR®, because it’s…

Broad – whole child, supports family  Welcoming – all about building love  Enriching – closeness brings progress 

DIR ‘quick guide’ …

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

Today’s Outline:  DIR

in School Programs  Reflective Process  Considering medication  Case examples  Your experiences

This handout will be posted on Circlestretch.com

School Programs IEP Goals: ideal vs. real – it’s ok to work from where you are.  Our Metaphor: The Learning Tree (+caregiver profile) 

The Learning Tree

Practical DIR at School Co-regulation, and avoiding mere sensory breaks.  Understanding engagement  Flow of increasingly richer interactions  Cuing a dyad, interpreting the situation, and slowing things down 

A Flow of Interaction

Find An Ally

Reflective Process  There

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

Reflective Process: in the moment  Humility:

you do not have the

‘answer’  Learn from staff to 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‚ž

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

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

Evidence based medicine, and informed consent

Specific Medications For details see circlestretch.com ď‚ž For a framework, see The Learning Tree (+caregiver profile) ď‚ž

Remember the Tree

Individual Differences – Charlie – Preschool 5/05 & Kindergar ten 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.

7. assess space, shape and materials.

-

Sequencing Execution Adaptation

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

7. assess space, shape and materials.

Can focus pretty well on an object now

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

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

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

]

Islands of support

Moderately effective in supporting ’50%’

Becoming consistent in ability to support

Effective except when stressed

Very Effective in supporting

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

Can predict when he will become upset

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

Becoming consistent in ability to support mellow

unflappable

Persistent attempts to engage him

Interested in the flow of activity, not interaction

directive

Moderately effective in supporting ’50%’

Effective except when stressed

Very Effective in supporting

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

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

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

Very Effective in supporting

Lots of Details to Rush Through Get the details of the rationale from circlestretch.com  I’ll slow down when we talk about the specific meds  We’ll work through the new stuff together – never really formally done before today – ever.  (and on no sleep – so it should be interesting…) 

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‚ž Allows doctors to use medications for whatever they think is appropriate ď‚ž

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…

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

Elements of 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

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”

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  Vested Interests  Convinced Clinicians

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

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

Working with doctors  Find

one you can work with  Keep the doctor in the loop  Don’t overwhelm with data  Doctors can be confused (“biomedical”)  Respectfully offer resources  Good doctor consult other doctors

Finding a doctor…  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

A Quick History of Medications in Autism: 



   

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

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

What kind of progress is important?

• •

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.

A Good Plan Is Complex: 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 

Sometimes the plan is not working:

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

The Central Question ď‚ž

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

Other Issues?

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

Other Common Reasons to Consider Medications

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

Reasons to Hold Off  Can’t

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

A General Approach:  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

and

possible treatments and fill in likely +’s & -’s, in a flexible decision matrix

 Availability - doctor MUST stay in touch with family and school

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…

• • • • • • • • • • • • • • • • • •

Activity, impulsivity Anger Attention Anxiety, specific fears Cognition Depression GI Distress Mood instability, irritability, aggression Motor Planning O/C, rigidity Perseverative Pain Reciprocal interaction Seizures Sensory Sensitivity & Processing Sleep Tics Others??

Targets

Ac

At

A

C

D

Moo

Mo tor Pla nni ng

GRIDDING OUT TARGET SYMPTOMS ti teVS. POSSIBLE n oTREATMENTS e d FOR DEVELOPMENTAL ANDvi LEARNING DISORDERS (INCLUDING ASDs) nt x g pr Insta

ty

io n

Stimulants

+/-

+/-

-

+/-

-

-

SSRIs

-

-

+/-

-/+

+?

-/+

Neuroleptics

+?

-?

+

-/+

+?

++?

AEDs

+?

-/+

+

-/ +?

+?

Steroids

-?

-?

+?

+?

Central Alpha Agonists

+?

+?

+?

-/+

Etc… LIST OTHER TREATMENTS!

i e t y

n i t i o n

es si o n

bility “aggr essio n”

+/-

O/ C, rigi dit y Per sev era tiv e

Re cip roc al int era cti on

Se ns or y Se nsi tivi ty

-

+?

-

+?

+?

-

+?

++??

+?

++?

-?

+?

+?

-/+

-?

+?

-?

+/-

1/+?

-/+?

+?

T i c s

-

S l e e p

E t c …

Com men ts

-

Wt Ht tics

-/+

Wt, Ht Sz

+

+

Wt. Sz TD NMS

+?

+ ?

+/-

Mult.

SE…

++?

-?

+ ?

-?

Mult SE…

+?

+?

+ ?

+

Sleep BP

Core Symptoms?

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

Medication may help core symptoms, but mostly indirectly…

 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.

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. 

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 

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.

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

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?

AEDs      

Anti-Epileptic Drugs (aka anti-seizure medications) So many and all so different in character For seizures, and for mood stabilization Might help other medications work better (stimulants, antidepressants) Combined pharmacology vs. polypharmacy Sudden sopping 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, weight gain, sedation, rash Trileptal (oxycarbezine) – ‘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 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

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

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 

Other Commonly Considered Medications… 

  

 

Straterra (atamoxetine) – for ADHD; may be as good as placebo, may act like an antidepressant (+/-) Wellbutrin (bupropion, etc.) Rozerem (ramelteon) – melatonin agonist SNRIs – Effexor (venlafaxine), Cymbalta (duloxetine), Remeron (mirtazepine), Serzone (nefazedone) Deseryl (trazodone) – antidepressant often used for sleep; cognitive side effects, priapism Buspar (an azaspirone) – mild, serotonergic cross reactions

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’

Meds that I often avoid…     



Paxil (paroxetine) - withdrawal Effexor (venlafaxine) - 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

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

Targets

Ac

At

A

C

D

Moo

Mo tor Pla nni ng

GRIDDING OUT TARGET SYMPTOMS ti teVS. POSSIBLE n oTREATMENTS e d FOR DEVELOPMENTAL ANDvi LEARNING DISORDERS (INCLUDING ASDs) nt x g pr Insta

ty

io n

Stimulants

+/-

+/-

-

+/-

-

-

SSRIs

-

-

+/-

-/+

+?

-/+

Neuroleptics

+?

-?

+

-/+

+?

++?

AEDs

+?

-/+

+

-/ +?

+?

Steroids

-?

-?

+?

+?

Central Alpha Agonists

+?

+?

+?

-/+

Etc… LIST OTHER TREATMENTS!

i e t y

n i t i o n

es si o n

bility “aggr essio n”

+/-

O/ C, rigi dit y Per sev era tiv e

Re cip roc al int era cti on

Se ns or y Se nsi tivi ty

-

+?

-

+?

+?

-

+?

++??

+?

++?

-?

+?

+?

-/+

-?

+?

-?

+/-

1/+?

-/+?

+?

T i c s

-

S l e e p

E t c …

Com men ts

-

Wt Ht tics

-/+

Wt, Ht Sz

+

+

Wt. Sz TD NMS

+?

+ ?

+/-

Mult.

SE…

++?

-?

+ ?

-?

Mult SE…

+?

+?

+ ?

+

Sleep BP

Getting back to the tree‌

Targets

Sen

Mot

Recep

Express

GRIDDING OUT TARGET SYMPTOMSsor VS.y POSSIBLE or TREATMENTS tive ive FOR DEVELOPMENTAL AND LEARNING DISORDERS (INCLUDING ASDs) Pro ton Comm Commu

ces sing

e and mot or Pla nni ng

unicat ion

nication

Visua l Spati al

‘Prax is’

Other medi cal

E t c …

Comm ents

Stimulants

Wt Ht tics

SSRIs

Wt, Ht Sz

Neuroleptics

Wt. Sz TD NMS

AEDs

Mult.

SE…

Steroids

Mult SE…

Central Alpha Agonists

Sleep BP

Etc… LIST OTHER TREATMENTS!

Targets

Co-

En

Ci

Fl

Sy

Lo

GRIDDING OUT TARGET SYMPTOMS reg gaVS. POSSIBLE rc oTREATMENTS m gic FOR DEVELOPMENTAL AND LEARNING DISORDERS (INCLUDING ASDs)

ula tio n

ge me nt

le s

w

b ol ic

al

Mul tica usal

Nua nce

Refl ecti ve

Nu mb er 10 ?

Et c …

Comme nts

Stimulants

Wt Ht tics

SSRIs

Wt, Ht Sz

Neuroleptics

Wt. Sz TD NMS

AEDs

Mult.

SE…

Steroids

Mult SE…

Central Alpha Agonists

Sleep BP

Etc… LIST OTHER TREATMENTS!

Targets

Readi ng…..

SYMPTOMS

GRIDDING OUT TARGET FOR DEVELOPMENTAL AND

Writin Arith Ethica g…… metic l VS. POSSIBLE TREATMENTS LEARNING DISORDERS….

(INCLUDINGrules ASDs) …

Trad e skills …

Swimm ing….

Etc…

Comments

Stimulants

Wt Ht tics

SSRIs

Wt, Ht Sz

Neuroleptics

Wt. Sz TD NMS

AEDs

Mult.

SE…

Steroids

Mult SE…

Central Alpha Agonists

Sleep BP

Etc… LIST OTHER TREATMENTS!

Targets

Co

Finding

Plea

GRIDDING OUT TARGET SYMPTOMS TREATMENTS mfoVS. POSSIBLE an sura FOR DEVELOPMENTAL AND LEARNING (INCLUDING ASDs) rtin DISORDERS appropria

g the chil d

te level of stimulatio n

ble enga ging the child

Readin g the child’s emotio nal signals

Respondi ng to the child’s emotiona l signals

Enco uragi ng the child ’s devel opme nt

E t c …

Comm ents

Stimulants

Wt Ht tics

SSRIs

Wt, Ht Sz

Neuroleptics

Wt. Sz TD NMS

AEDs

Mult.

SE…

Steroids

Mult SE…

Central Alpha Agonists

Sleep BP

Etc… LIST OTHER TREATMENTS!

Case Examples

Abnormal Involuntary Movement Scale (AIMS)

Summary: Look at the whole picture  Be careful with meds  Engage the Child 

Your Experiences?