The Role of Medication and Other Biological Approaches in Infants and Early Child Mental Health aka Psychiatric Medications and Young Children Josh Feder MD We Can’t Wait September 28, 2013
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Director of Research, Graduate School, Interdisciplinary Council on Developmental and Learning Disorders
Assistant Clinical Professor, Voluntary Department of Psychiatry, University of California at San Diego 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 – early intervention Circlestretch – community resource Cherry Crisp – media company
Specific Gratitude • Jeff, Jeff, Jeff: It’s always been about the Jeff • ECMHSL group • Local Colleagues: DIR, Rady/ UCSD, etc., etc.
Learning Objectives • Name the three core principles of Evidence Based Practice. • Name and Describe three basic levels of a developmental social-emotional function. • Understand that medications may help in Infant and Childhood Mental health but that they do not replace a good overall plan.
Outline
(Partial Bait & Switch)
Evidence Based Medicine/ Practice The bio-psychosocial model & DIR Medicine and other biological approaches
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Don’t sweat the details - this talk will be posted on‌
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Where to start? It’s a big universe
scientific knowledge is a lot smaller than nature and we often don’t have exact answers of what to do
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If we don’t know exactly what to do, 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.
Striving for 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)
the three core principles of Evidence Based Practice
We want to figure out how to help infants and young children
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For starters: There’s no such thing as a baby‌
Minimum Meme = baby+caregiver
Similarly‌
We can only understand a child in context
When we think about helping a child function better
We need to think about supporting caregivers
It’s Complicated: Bio - Psycho - Social Biological – Psychological –Social George Engel: cardiac care Carl Whittaker: the buffy coat
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It’s Complicated: Bio - Psycho - Social Covers a broadening range of possible influences Gets you thinking about all the factors involved Brainstorm with BPS as your guide
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Example: Baby’s not sleeping BPS/SPB
Spiritual – Big Bang (OMG!) Galactic: solar, gamma rays (Courchesne) Global: Environmental (Japan radioactivity?, rising tides?), Geopolitical (dad at war) National: Environmental (weather systems, wild fires); Political (ACT Today) Regional: Microenvironmental (dry air; CA autism clusters & SES); State cuts Local: Environmental (artillery exercises, red tide); Political (school district pink slips) Extended Family: far away; ‘Ghosts’; some with genetic (?) issues; babysitter issues? Immediate Family: Dad deployed, mom is ‘down’ and exhausted, worried about SIDS Child: responses to not getting much good mom time (anaclitic?); other (DMIC) General biological: not sleeping well, not eating well, hydration, medications Organ systems: teething, CNS, GI, Immune (OM?), Skin (rash), Hepatic, Renal, injury Cellular: DNA, RNA, mitochondrial function, insulin resistance Biomolecular: receptors and intracellular signaling (histamine, serotonin, etc.) Inorganic molecular/elemental: lead. CO, CO2, post fire particulate matter Atomic and subatomic: gamma rays, 11 dimensional universe
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It’s Always So Complicated We need an Organizing Philosophy
Using DIR as an Organizing Philosophy for a BPS Developmental Approach • Broad – whole child, supports family • Welcoming – all about building love • Enriching – closeness can bring progress
DIR in a nutshell Stanley Greenspan & Serena Wieder
• Developmental levels – from regulation, to warm trust, and then a flow of enriching interactions • Individual Differences – sensory, motor, communication, visual-spatial, cognitive, etc. • Relationship Based – all about connecting, and making time with others for support and help
Developmental three basic levels of a developmental social-emotional function
I. Regulation – calm and alert II. Engagement – truly connected III – XV. Reciprocity – flow of interaction that is gradually more complex and abstract
Regulation - Calm and Alert • Most basic requirement of all • We (the world) need to help parents be calm so child can be calm - support, therapy, medication for parent? • How able is the child, developmentally? Homeostasis – arousal level & stability • Does child have specific problems that medication might address to help the child be regulated (attention, impulsivity, overaroused/hypervigilant, low arousal, seizures etc.)?
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Engagement – Truly Connected Affective connection drives internal motivation for
communicating and learning – if you don’t care, you don’t think and adapt • Help parents to be emotionally present and to find or create loving moments • How able is the child, developmentally? Needs to be regulated; child’s repeated repair of engagement brings resilience (Tronick) • Does child have specific problems that medication might address to help the child (e.g., failure of natural positive exploratory attitude – depression, anxiety, etc.?)
Reciprocity - Flow of Interaction
• Circles of interaction, many of them in the course of solving the social problem of the moment (eating, playing, toileting, learning, etc.) • Help parents build on the child’s lead to create a shared, meaningful experience • How able is the child, developmentally? Needs to be regulated, engaged, to respond, repair • Does child have specific problems that medication might address to help the child (rigid or negative thinking, irritability, etc.?)
Observations: •Child – physical, behavioral •Relationships with caregivers •In office, at home, in other care settings, class, activities Other Information to consider: •Collateral information from other caregivers, teachers, health care providers (OT, PT, speech, etc.) •Review of records – medical, preschool, etc. •Laboratory studies
Developmental: stability of capacity for… •Regulation- Engagement – Reciprocity Individual Differences: qualities of child’s… •Sensory – motor – receptive – expressive – visual – exec •Executive: idea, plan, steps, execute, adapt Relationship: caregiver abilities to… •Comfort - calm & alert; engage; read cues – respond – support development •What does the support system look like?
Developmental: •Supporting Regulation- Engagement – Reciprocity Individual Differences: •Other Therapies (OT, PT, SL, Ed, etc.) •Medications and other biological approaches Relationship: •Coaching parents &caregivers •Shoring up support systems: safety, reflective opportunities, reflective institutions
Developmental: •Supporting Regulation- Engagement – Reciprocity Individual Differences: •Other Therapies (OT, PT, SL, Ed, etc.) •Medications and other biological approaches Relationship: •Coaching parents &caregivers •Shoring up support systems: safety, reflective opportunities, reflective institutions
Medications and other biological approaches
Medication and Other Approaches For Our Family
• 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 Build the care plan: and once that is in place, if it appears medicaiton may help then… 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 thing than one thing at a time. 41
Name Your Symptoms…
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Infants and Young Children are Different
Infants and Young Children are Different Liver: enzymes (more of some, less of others), liver to body ratio Plasma: more relative body water Plasma protein binding is reduced – fetal albumin less binding Less fat and so less lipid filling, release, etc. Kidney glomerular filtration is not fully developed at birth: ‘adult by 2’ (more changes in adolescence) Brain: fewer neurons and far fewer dendrites with different size, construction, tracts, & receptors; BBB is more permeable Gastrointestinal pH is acidic in neonates: acidic medication absorb well, more base ones do not Skin, eye membrane permeability is increased (think toxins)
Look it up…
History of psychotropic use in Infants and Young Children: Mom’s meds through placenta or breastfeeding Anti Epileptic Drugs: for seizures – dangers of polypharmacy Steroids: usually for seizures - side effects problematic Neuroleptic (antiosychotic) cousins – in gastrointestinal treatment Lithium – early in the bipolar child literature Stimulants – PATS: the first large scale prospective study of psychotropics in preschoolers
Evidence Based Practice and psychotropic use in Infants and Young Children: Research is limited, but may be supportive. We borrow from adult world but this is not necessarily appropriate to do Clinical experience typically suggests we start low, go slow, and try not to change more than one thing at a time. Family Culture and Values might lead to request for medication when we are not comfortable (e.g. no bigger plan in place or trying to have a child conform to a harsh regime at home or school) or shunning them when we feel they might be very helpful or even vitally important (e.g. clear severe bipolar). Informed consent – Parents should almost always be the actual decision makers. Ethical, rational approaches often require lots of time to talk and think things through together in a reflective and ongoing process throughout the course of care
• Regulation and co-regulation by treating, e.g., attention, impulsivity, over-aroused/hypervigilant, low arousal, etc. also treat seizures, esp. absence seizures. • Engagement: Widen availability for and tolerance of emotions so the person is less likely to become overwhelmed, withdraw; more able to maintain engagement failure of natural positive exploratory attitude – depression, anxiety, etc. Better able to repair and build resilience over time. • Reciprocity: Treat co-occurring conditions/ symptoms, e.g., negative thinking, irritability; mood stability, rigid thinking, perseveration. Might promote abstract reasoning and thinking. 48
Stimulants • • • •
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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. 50
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.
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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? 52
Abnormal Involuntary Movement Scale (AIMS)
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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
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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?
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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
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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? 57
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 58
More Others… • Lithium – great mood stabilizer; anti-suicidal; bipolar-ASD 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’ 59
Meds I avoid…at all ages • 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
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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 61
More on clinical experience ‘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 • Always keep the bigger plan in mind – if meds ‘aren’t working’ is there something else going on? 62
• 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 63
Potions, etc.
Common Household 'Potions' Breast milk: mother of them all - from preventing illness through antibodies to improving cognitive outcomes and reducing rates of later conduct disorder Hydration – and sports drinks (fructose/ electrolytes). Chicken soup for colds Gatorade for rehydration - fructose and electrolytes Tea and honey (and whiskey?) for sore throats Coffee - reduces depression in women Whiskey on gums for teething 65
Various Common Supplements Herbs: parsley for digestion and better breath Minerals: zinc: may prevent depression; chromium may help depression Omega 3 fatty acids Eicosapentaenoic Acid (EPA) and Docosahexaenoic Acid (DHA) for depression and for mood stability, as well as to protect against Tardive Dyskinesia with neuroleptics Amino acids: inositol (depression, schizophrenia); Dcycloserine (OCD); L-tryptophan (sleep) Vitamins: D3 (depression, etc.), B vitamins (relief of stress); Niacin (B3): reduces cholesterol, triglycerides. Really Bad ones: ‘bath salts’ (mephedrone), THC psychosis risk, loss of hippocampal cells 66
Other Available Means… Exercise: helps depression, anxiety; yoga; Tai Chi Sleep (also a future lab – don’t pick this one) Meditation: helps depression, anxiety, pain Light: Sunlight: serotonin; Blue and green light: blue can keep you up, blue and green both can change emotional processing in persons with Seasonal Affective Disorder Music: Mozart, Bach, etc. Cultural. Minor vs. Major keys. Music therapy does improve depressive symptoms in the moment. 67
Summary: Organize your thinking around Regulation, Engagement and Reciprocity, what the world can do to help parents support these capacities in children. Look at what research there is, use your experience to think about what makes sense, and help families make ongoing informed decisions based on their own culture, values, and development. Medications do not make up for a bad plan, but they might help a good one to succeed.
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