Things to consider in the use of medication for persons with developmental and learning disorders
Assistant Clinical Professor, Dept of Psychiatry, University of California at San Diego School of Medicine Faculty, Interdisciplinary Council on Developmental and Learning Disorders
ICDL Faculty – minimal - review of clinical write ups, travel and room for summer institute NIMH/ Duke University – minimal – administrative time for pharmacogenetic research
Quick history: Magda Campbell: haloperidol helps social learning; others: methylphenidate causes side effects without benefit. Today: we try to treat target symptoms, carefully, based on responses in other conditions to medications. Takes time to assess, and re-assess. Marketing, and side effects, and efficacy studies. Efficiency study: CAPTN (Duke: John March, el al – I’m an et al…).
Most
people consider meds because they feel stuck, maybe desperate Emergencies: aggression, depression, others? Lack of progress: in what areas?
What
do we want for he child? What the meaning of the disability is to the family and to your child? Goal: a meaningful life socially, emotionally, and cognitively. Requires a plan, and medication alone is not a plan.
regulatory
issues/ motor and sensory areas addressed engagement and reciprocity language/ communication cognition/ learning daily living skills followed by broader and broader areas of life skills, from school and playground to vocational skills.
Mirror
neuron systems Joint attention and relationship-based intervention GxE: genetics and environment Pharmacogenetics And then there is always the math…
Are
we asking too much of the child? Of the family? Of the school?
Low Support - Low Expectation (neglect…)
Low Support - High Expectation (‘Just do it…’)
High Support - Low Expectation (walking on eggshells, more and more constricted…)
High Support - High Expectation (respectful coaching)
Is
the program adequate? Will they change the child’s brain and actually fix it? Will they injure the child? What should I expect?
Losing
time while pulling the program together Doing as much as possible Awakenings – should we go for a miracle?
We
do not know enough to say ‘you really should medicate’ If there is no emergency, you have more time to think about it When parents differ, if makes for more thoughtful planning
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, and collateral 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
Support
regulation and co-regulation by treating symptoms that get in the way, e.g., impulsivity, inattention, anxiety, rigid thinking, perseveration.
Widen
tolerance of affective experience so the person is less likely to become overwhelmed.
Treat
co-morbid conditions, e.g., depression.
Possibly: allow
for or promote improved ability for abstract reasoning and thinking.
Easy for the treatment team to react and overuse medications Side effects often create significant difficulties, e.g., behavioral activation (SSRIs), increased perseveration (stimulants), sedation (some anticonvulsants, others). Team treatment often becomes ‘all about the medication’, ignoring engagement, other factors. Bottom line: medication most probably do not treat core symptoms, but might create more affective availability, if you can avoid significant side effects.
Find
with
a doctor you like and feel you can work
Keep
the doctor in the loop
Don’t
overwhelm the doctor with data
Think
carefully before rapid, large changes in dose or before changing more thing than one thing at a time.
Respectfully
offer resources – don’t expect your doctor will read a book for you, but do expect your doctor is interested in other opinions from other doctors
ď‚ž Look
for Basic Competence: APBNBoard Certified Child and Adolescent Psychiatrists were checked for competence in assessing autism, and for use of collateral information from family, school, and other professionals. ď‚ž Look for Honesty: AACAP = a promise to be ethical and do their best
Helping
parents determine when medication may be worth considering Helping families navigate well to utilize their doctors and other providers Helping families orchestrate the whole set of interventions into a coherent and manageable plan Good Luck!