Post on 30-May-2018
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
1/64
UCSD RCHSDMarch 24, 2009
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
2/64
Assistant Clinical Professor,
Dept of Psychiatry, University ofCalifornia at San Diego School ofMedicine
Faculty, Interdisciplinary Council onDevelopmental and Learning
Disorders
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
3/64
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
4/64
ICDL Faculty minimal - review of
clinical write ups, travel and roomfor summer institute
NIMH/ Duke University minimal
administrative time forpharmacogenetic research
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
5/64
a novella on the use of medication (20 min)
brief monograph:medication from a DIR perspective (3 min)
fantasies and nightmaresin med-land (2 min)
the story of a real boyand a diagnostic system (20 min)
your stories(15 min)
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
6/64
all slides will be posted on
circlestretch.blogspot.comfollow the blue dot!
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
7/64
Quick history: Magda Campbell: haloperidolhelps social learning; others:methylphenidate causes side effects withoutbenefit.
Today: we try to treat target symptoms,carefully, based on responses in otherconditions 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 Im an et al).
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
8/64
Most people consider meds becausethey feel stuck, maybe desperateEmergencies: aggression, depression,
others?Lack of progress
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
9/64
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.
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
10/64
regulatory issues/ motor and sensory areasaddressed
engagement and reciprocity (vs. focus on
compliance) language/ communicationcognition/ learningdaily living skills followed by broader and
broader areas of life skills, from school andplayground to vocational skills.
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
11/64
Are we asking too much of the child?
Of the family?Of the school?
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
12/64
Low Support - Low Expectation
(neglect)
Low Support - High Expectation
(Just do it)
High Support - Low Expectation
(walking on eggshells, more andmore constrictede.g. gamers)
High Support - HighExpectation
(respectful coaching)
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
13/64
Is the program adequate?
Will they change the childs brain andactually fix it?Will they injure the child?
What should I expect?
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
14/64
Losing time while pulling the programtogetherDoing as much as possibleAwakenings should we go for a
miracle?
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
15/64
We do not know enough to say you
really should medicateIf there is no emergency, you have
more time to think about it
When parents differ, it can be anopportunity for more thoughtfulplanning
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
16/64
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, andcollateral 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
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
17/64
Easy for the treatment team to react andoveruse medications
Side effects often create significantdifficulties, e.g., behavioral activation
(SSRIs), increased perseveration(stimulants), sedation (someanticonvulsants, others).
Team treatment often becomes all aboutthe medication, ignoring engagement,
other factors.Bottom line: medication probably does nottreat core symptoms, but might create moreaffective availability, if you can avoidsignificant side effects.
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
18/64
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
19/64
elements of informed consent
the process of informed consentnearly everything is experimentalwe have to track this fairly closely
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
20/64
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 USEOF MEDICATIONS IS VOLUNTARY AND I PLAN TO WORK WITH THE DOCTOR TO MAKE THE BEST USEOF THESE.
I CONSENT TO THE TREATMENT. IF MEDICATION IS PART OF THE TREATMENT PLAN AND I WILLREQUEST 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
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
21/64
Find a doctor you like and feel you canwork with
Keep the doctor in the loopDont overwhelm the doctor with data
Think carefully before rapid, largechanges in dose or before changingmore thing than one thing at a time.
Respectfully offer resources dont expect
your doctor will read a book for you, but doexpect your doctor is interested in otheropinions from other doctors
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
22/64
Look for Basic Competence: APBNBoard Certified Child and AdolescentPsychiatrists were checked forcompetence in assessing autism, andfor use of collateral information fromfamily, school, and other
professionals.Look for Honesty: AACAP = a
promise to be ethical and do their
best
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
23/64
Helping parents determine whenmedication may be worth consideringHelping families navigate well to
utilize their doctors and otherprovidersHelping families orchestrate the
whole set of interventions into acoherent and manageable planGood Luck!
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
24/64
Can Medications Help Kids HaveBetter,
More Productive RelationshipsWith Us?
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
25/64
Co-regulationEngagementCirclesFlowSymbolic thinkingLogical social problem solvingMulti-causal thinkingGrey area thinkingReflective thinking, stable sense of self,
internal standard
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
26/64
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
27/64
Sensory processingPostural control/ motor planningReceptive communicationExpressive communicationVisual-spatial functionPraxis: ideation, planning,
sequencing, execution, adaptation
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
28/64
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
29/64
Support regulation and co-regulation bytreating symptoms that get in the way,e.g., impulsivity, inattention, anxiety,
rigid thinking, perseveration.Widen tolerance of affective experienceso the person is less likely to becomeoverwhelmed.
Treat co-morbid conditions, e.g.,depression.Possibly: allow for or promote improved
ability for abstract reasoning and
thinking.
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
30/64
DIR is the main courseMeds are the pickles
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
31/64
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
32/64
A Good Enough WizardUnpredictable Potions
Nefarious Forces:syndromes & systems(affecting schools, social services, and industry)
and
transferences & countertransferences(invisible and everpresent)
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
33/64
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
34/64
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
35/64
SeizuresWeight gainInsulin resistanceTardive DyskinesiaNeuroleptic Malignant Syndrome
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
36/64
perseveration, anxiety, depressionmay improveoften the benefits are outweighed by
overactivity, inattention, or evenmania, rarely seizures, and sweatingas a precursor to serotonin syndrome
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
37/64
For mood stabilization, oh, and fewer seizures Well Mrs Farkel Liver, pancreas, weight gain,
sedation, incontinence, drooling, and if you everwant to have babies beware of PCOS, loss of whitecells, bleeding problemss
Tegretols blood and cardiac problems Lamictals scathing rash, and unweildy interaction
with Depakote
Topamax: wt loss, but language loss; unreliability,decreased sweatingOthers
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
38/64
The plan that lived, due to betterfocus and less overactivityRagged sleep, ratty moods, thin waifs
with sunken eyes, stupors, tics, andoccasional paranoia; cardiac andgrowth issues
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
39/64
Reliable anxiolytic, helpful forseizuresReliable loss of memory and motor
control, with inability to benefit fromlearning and high risk of falling andautomobile accidents
Addiction is rampantALL MEMBERS OF THIS CLASS
(BENZODIAZEPINES) ARE
PROBLEMATIC
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
40/64
The number one cause of death byantidepressants due to overdose in thedays before SSRIs
CARDIOTOXIC: have people LOCK THEMUP! and get serial EKGs w/ Cardiologistreadings
Still, they are as effective or more effectivethan any other antidepressants we have,and clomipramine is more effective,generally than SSRIs for OCD.
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
41/64
Find a good enough Wizard, one whoknows the stories, good and bad, andwho listens to you and your people
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
42/64
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
43/64
case synopsisvideo clipsanalysisdiscussion
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
44/64
K Searcy - ?Meds for anxiety in
autism, Jan 2008Failure to make gains despitemassive services
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
45/64
AutismSAFETY fingers in eyesextremely perseverative (fans)
anxietyover-activitytantrums language
hard to take him out, (esp. dad)?seizures.
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
46/64
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 didnt
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.
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
47/64
break the door MOV00732.MPG(0:10)Malingo Toya song and dance (0:55)This Little Piggy (4:50)
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
48/64
Axis I Primary DiagnosisAxis II - Functional Emotional
Developmental Capacities
Axis IIIRegulatorySensory ProcessingCapacities
AxisIVLanguage CapacitiesAxisVVisuospatial Capacities
AxisVIChildCaregiver and Family PatternsAxisVIIStress
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
49/64
Axis I Primary Diagnosis
Axis II - Functional EmotionalDevelopmental Capacities
Axis IIIRegulatorySensory Processing Capacities AxisIVLanguage Capacities AxisVVisuospatial Capacities AxisVIChildCaregiver and Family Patterns AxisVIIStress
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
50/64
Notthere
Barely Islands Expands
Comesback
Ok ifnotstressed
Ok forage
Co-regulate
3/08 9/08 3/09
Engage 3/08 9/08 3/09
Circles 3/08 9/08 3/09
Flow 3/08 9/08 3/09
Symbolic 3/08 9/08, 3/09
Logical3/08,3/07,3/08
Multicausal
3/08,3/07,3/08
Grey area 3/08,3/07,3/08
Reflective 3/08,3/07,3/08
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
51/64
03/08 moments ofgleam and a couple of circleswhen I get playfully in his way unplug the fan orstop him from crawling under my desk
09/08 - join and shift the OC on AC to ram intocouch; 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 moreelaboration of circles and some flow with her; can talk abouttoes, but not really more symbolic per se.
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
52/64
Axis I Primary Diagnosis Axis II - Functional Emotional Developmental Capacities
Axis IIIRegulatorySensory
Processing CapacitiesAxis IVLanguage CapacitiesAxis VVisuospatial Capacities AxisVIChildCaregiver and Family Patterns
AxisVIIStress
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
53/64
Sensory
Postural Response toCommunication
Intent toCommunicate
VisualExploration
Praxis -
Sensory
seeking,distractible
Auditory
Visual
Tactile
Vestibular
Proprio-
ceptive
Taste
Odor
Best when core is
supported
1 indicate desires
----3/08----
2. mirror gestures
3. imitate gesture
4. Imitate withpurpose.
----9/08----5. Obtain desires6. interact:- exploration-purposeful
----3/09----
- self help
-interactions
Cues into important
words
Orient
----3/08----
2. key tones3. key gestures
4. key words
----9/08----5. Switch auditoryattention back andforth6. Follow directions7. Understand W ?s ----3/09----8.abstractconversation.
Often
unintelligible
Mirrorvocalizations ----3/08----
2.. Mirrorgestures
3. gestures
4. sounds
5.words----9/08----
6. two word
7. Sentences----3/09----
8. logical flow.
Spots fans at distance;
fingers in eyes; rare
gleam
focus on object
----3/08----
2. Alternate gaze3. Follow
anothers gazeto determineintent.3. Switch visualattention----9/08----4. visual figureground5. search forobject----3/09----
6. search twoareas of room7. assess space,shape andmaterials.
Perseverative
ideas; canexpand w/support
Ideation----3/08----
Planning(including
sensoryknowledge to dothis)----9/08----
Sequencing----3/09----
Execution
Adaptation
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
54/64
Axis I Primary Diagnosis Axis II - Functional Emotional Developmental Capacities Axis IIIRegulatorySensory Processing Capacities AxisIVLanguage Capacities AxisVVisuospatial Capacities
AxisVIChildCaregiver and FamilyPatternsAxisVIIStress
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
55/64
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
56/64
Axis I Primary Diagnosis Axis II - Functional Emotional Developmental Capacities Axis IIIRegulatorySensory Processing Capacities AxisIVLanguage Capacities AxisVVisuospatial Capacities AxisVIChildCaregiver and Family Patterns AxisVIIStress
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
57/64
100. Interactive Disorders 200. Regulatory Sensory Processing Disorders
300. Neurodevelopmental
Disorders of Relating andCommunicating 400. Language Disorders 500. Learning Challenges
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
58/64
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 ideasmakesrapid progress in a comprehensive program
300.2 Type II:Purposeful Problem Solving, with Constrictions; as above but only
fleeting social problem solvingtend to make steady, methodicalprogress
300.3 Type III: Intermittantly Engaged and Purposeful; only fleeting attention andengagement, 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
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
59/64
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
60/64
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
61/64
Mar 08: we are in a dangerous crisis dysregulatedand perseverative
Sept 08: with meds and direction to the intervention,
he can be entrained into collaborativeinteractionMar 09: we are confident that with coaching
his capacities will expand
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
62/64
Medication management, and moreGuiding the whole team, once and
twice removed.As the prescribing physician I have
responsibility, accountability, andleverage - they come back
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
63/64
Will you be careful with the meds?
Will you look at the whole picture?Will you continue to learn and
explore?
8/14/2019 Psychotropic Medication in the Treatment of Developmental and Learning Disorders
64/64