Psychotropic medication in the treatment of developmental and learning disorders by Circlestretch

UCSD RCHSD March 24, 2009

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

a novella on the use of medication (20 min) brief monograph: medication from a DIRÂŽ perspective (3 min) fantasies and nightmares in med-land (2 min) the story of a real boy and a diagnostic system (20 min) your storiesâ&#x20AC;Ś(15 min)

ď&#x201A;&#x17E;

all slides will be posted on

circlestretch.blogspot.com ď&#x201A;&#x17E; follow the blue dot!

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.  Big issues: marketing, 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

 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.

 regulatory

issues/ motor and sensory areas

addressed  engagement and reciprocity (vs. focus on compliance)  language/ communication  cognition/ learning  daily living skills followed by broader and broader areas of life skills, from school and playground to vocational skills.

 Are

we asking too much of the child?  Of the family?  Of the school?

Low Support - Low Expectation

Low Support - High Expectation

(neglect…)

(‘Just do it…’)

High Support - Low Expectation

High Support - High Expectation

(walking on eggshells, more and more constricted…e.g. gamers)

(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, it can be an opportunity 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

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 probably does not treat core symptoms, but might create more affective availability, if you can avoid significant side effects. 

 elements

of informed consent  the process of informed consent  ‘nearly everything is experimental’  ‘we have to track this fairly closely’

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 USE OF MEDICATIONS IS VOLUNTARY AND I PLAN TO WORK WITH THE DOCTOR TO MAKE THE BEST USE OF THESE. I CONSENT TO THE TREATMENT. IF MEDICATION IS PART OF THE TREATMENT PLAN AND I WILL REQUEST 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

 Find

a doctor you like and feel you can work

with  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&#x201A;&#x17E; Look

for Basic Competence: APBN Board 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&#x201A;&#x17E; 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!

Can Medications Help Kids Have Better, More Productive Relationships With Us?

 Co-regulation  Engagement  Circles  Flow

 Symbolic

thinking  Logical social problem solving  Multi-causal thinking  Grey area thinking  Reflective thinking, stable sense of self, internal standard

 Sensory

processing  Postural control/ motor planning  Receptive communication  Expressive communication  Visual-spatial function  Praxis: ideation, planning, sequencing, execution, adaptation

 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.

 DIR®

is the main course  Meds are the pickles…

A

Good Enough Wizard  Unpredictable Potions  Nefarious Forces: syndromes & systems (affecting schools, social services, and industry) and transferences & countertransferences (invisible and everpresent)

ď&#x201A;&#x17E; Peace, from

nearly anything that ails you ď&#x201A;&#x17E; Rare Miraculous Awakenings

 Seizures  Weight

gain  Insulin resistance  Tardive Dyskinesia  Neuroleptic Malignant Syndrome

ď&#x201A;&#x17E; perseveration, anxiety, depression

may

improve ď&#x201A;&#x17E; often the benefits are outweighed by overactivity, inattention, or even mania, rarely seizures, and sweating as a precursor to serotonin syndrome

 

  



For mood stabilization, oh, and fewer seizures “Well Mrs Farkel…” Liver, pancreas, weight gain, sedation, incontinence, drooling, and if you ever want to have babies beware of PCOS, loss of white cells, bleeding problemss Tegretol’s blood and cardiac problems Lamictal’s scathing rash, and unweildy interaction with Depakote Topamax: wt loss, but language loss; unreliability, decreased sweating

Others…

 ‘The

plan that lived’, due to better focus and less overactivity  Ragged sleep, ratty moods, thin waifs with sunken eyes, stupors, tics, and occasional paranoia; cardiac and growth issues

 Reliable

anxiolytic, helpful for seizures  Reliable loss of memory and motor control, with inability to benefit from learning and high risk of falling and automobile accidents  Addiction is rampant  ALL MEMBERS OF THIS CLASS (BENZODIAZEPINES) ARE PROBLEMATIC

 The

number one cause of death by antidepressants due to overdose in the days before SSRIs – CARDIOTOXIC: have people LOCK THEM UP! and get serial EKGs w/ Cardiologist readings

 Still, they

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

ď&#x201A;&#x17E; Find

a good enough Wizard, one who knows the stories, good and bad, and who listens to you and your people

 case

synopsis  video clips  analysis  discussion

ď&#x201A;&#x17E;K

Searcy - ?Meds for anxiety in autism, Jan 2008 ď&#x201A;&#x17E; Failure to make gains despite massive services

 Autism

 SAFETY

– fingers in eyes  extremely perseverative (fans)  anxiety  over-activity  tantrums  language  hard to take him out, (esp. dad)  ?seizures.

   

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 didn’t 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.

 ‘break

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

 Axis

I – Primary Diagnosis  Axis II - Functional Emotional Developmental Capacities  Axis III‐Regulatory‐Sensory Processing Capacities  AxisIV‐Language Capacities  AxisV‐Visuospatial Capacities  AxisVI‐Child‐Caregiver and Family Patterns  AxisVII‐Stress



Axis I – Primary Diagnosis

Axis

II - Functional Emotional Developmental Capacities

    

Axis III‐Regulatory‐Sensory Processing Capacities AxisIV‐Language Capacities AxisV‐Visuospatial Capacities AxisVI‐Child‐Caregiver and Family Patterns AxisVII‐Stress

Not there

Barely

Co-regulate

Islands 3/08

9/08

3/08

Engage Circles

3/08 3/08

Flow Symbolic

3/08

Logical

3/08,3/07,3/08

Multicausal

3/08,3/07,3/08

Grey area

3/08,3/07,3/08

Reflective

3/08,3/07,3/08

9/08, 3/09

3/09

9/08 9/08

9/08

Expands

3/09 3/09

3/09

Comes back

Ok if not stressed

Ok for age

03/08 – moments of gleam and a couple of circles when I get playfully in his way unplug the fan or stop him from crawling under my desk

09/08 - join and shift the OC on AC to ram into couch; 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 more elaboration of circles and some flow with her; can talk about toes, but not really more symbolic per se.

 

Axis I – Primary Diagnosis Axis II - Functional Emotional Developmental Capacities

III‐Regulatory‐Sensory Processing Capacities Axis IV‐Language Capacities Axis V‐Visuospatial Capacities Axis

 

AxisVI‐Child‐Caregiver and Family Patterns AxisVII‐Stress

Sensor y

Postural

Response to Communication

Intent to Communicat e

Visual Exploration

Praxis -

Sensory seeking, distractible

Best when core is supported

Cues into important words

Often unintelligible

Spots fans at distance; fingers in eyes; rare gleam

Perseverative ideas; can expand w/ support

Auditory

1 indicate desires

1.Orient

1.Mirror

Visual

----3/08----

Tactile

2. mirror gestures

Vestibular

3. imitate gesture

Proprioceptive Taste Odor

4. Imitate with purpose. ----9/08---5. Obtain desires 6. interact: - exploration -purposeful ----3/09---- self help -interactions

----3/08---2. key tones 3. key gestures 4. key words ----9/08---5. Switch auditory attention back and forth 6. Follow directions 7. Understand W ?’s ----3/09---8.abstract conversation.

vocalizations ----3/08----

2.. Mirror gestures 3. gestures 4. sounds 5.words ----9/08---6. two –word 7. Sentences ----3/09---8. logical flow.

1.focus

on object

----3/08---2. Alternate gaze 3. Follow another’s gaze to determine intent. 3. Switch visual attention ----9/08---4. visual figure ground 5. search for object ----3/09---6. search two areas of room 7. assess space, shape and materials.

Ideation ----3/08---Planning (including sensory knowledge to do this) ----9/08---Sequencing ----3/09---Execution Adaptation

    

Axis I – Primary Diagnosis Axis II - Functional Emotional Developmental Capacities Axis III‐Regulatory‐Sensory Processing Capacities AxisIV‐Language Capacities AxisV‐Visuospatial Capacities

AxisVI‐Child‐Caregiver

Patterns AxisVII‐Stress

and Family

    

Learned to quiz him, and quizzing him Can engage in some back and forth, coachable Discomfort with him in public –so different from other kids - improving Stress: eye issue harrowing, but improving as he becomes more connected. MANY OF OUR FAMILIES HAVE A FORM OF PTSD!

Axis      

I – Primary Diagnosis

Axis II - Functional Emotional Developmental Capacities Axis III‐Regulatory‐Sensory Processing Capacities AxisIV‐Language Capacities AxisV‐Visuospatial Capacities AxisVI‐Child‐Caregiver and Family Patterns AxisVII‐Stress

 

100. Interactive Disorders 200. Regulatory Sensory Processing Disorders

300.

Neurodevelopmental Disorders of Relating and Communicating

 

400. Language Disorders 500. Learning Challenges



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 ideas ‐makes

rapid progress in a comprehensive program 

300.2 Type II: Purposeful Problem Solving, with Constrictions; as above but only fleeting social problem solving‐tend to make steady, methodical progress



300.3 Type III: Intermittantly Engaged and Purposeful; only fleeting attention and engagement, 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

ď&#x201A;&#x17E;

ICDL DIR DMIC AXIS I 300.3 NDRC level III:

slow progress when he has lots of support.

 What works: early on getting in the way, modifying perseveration, getting him on his back, fanning him, gradually more able to follow his lead, extending interactions.  What doesn’t work: didactics, adding ideas too quickly

 Why: early on we used the drive of his perseveration to power interaction, now can often engage him over less intense things or using shared experiences (little piggies); position and physical support are still key to his ability to sustain interaction.  Medications have been very helpful to this child, allowing him to respond to developmentally supportive intervention.

 Mar

08: we are in a dangerous crisis – dysregulated and

perseverative

 Sept

08: with meds and direction to the intervention, he can be ‘entrained’ into collaborative interaction  Mar 09: we are confident that with coaching his capacities will expand

 Medication

management, and more…  Guiding the whole team, once and twice removed.  As the prescribing physician I have responsibility, accountability, and leverage - they come back

 Will

you be careful with the meds?  Will you look at the whole picture?  Will you continue to learn and explore?