Medication Support for DIR Programs October 28 2011 Tel Aviv

7/28/2019 Medication Support for DIR Programs October 28 2011 Tel Aviv

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Joshua D. Feder, MD

October 28, 2011

Tel Aviv, Israel

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Redacted for Posting

Case material removed

Questions? email [email protected]

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Director of Research, Graduate School,

Interdisciplinary Council on

Developmental and Learning

Disorders

Assistant Clinical Professor,

Dept of Psychiatry, University ofCalifornia at San Diego School of

Medicine

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ICDL Graduate School

ICDL Southern California Regional Institute

NIMH/ Duke University/Pfizer

SymPlay, LLC

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Feder 411

Math, Engineering, and Developmental

Disorders beginning 1978.

US Navy Child Psychiatry

Mike 1990 (1992)

Greenspan and Wieder 1993

Career expansion: clinic, teaching,

research, advocacy, tech development

and arts & media.

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The DIR/Floortime Model

Reflective Process

Support for the DIR Model

Considering medication

Case examplesYour experiences

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But First,

Some Commercials Because we build ideas together

And you can join us in the effort!

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Working Together for

Parent Choice!

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The Southern California

DIR/Floortime

Regional Institute

Pasadena, California

February 24-26, 2012

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Thank You!

Families say a silent thank you

Greenspan & Wieder

Mara Goverman

Daniel Carlat

David Sackett (et. al.)

Ricki Robinson

Michael Chez

So many others 14


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Assumptions

Varying familiarity with DIR/Floortime

and the supporing research.

Varying understanding of EvidenceBased Practice

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Conclusions:

The program is paramount.

Reflective process is the key to a goodprogram.

Medication might help a good progam

work better

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Why DIR?

because its

Broad whole child, supports family

Welcoming all about building love

Enriching closeness brings progress in

relating, communicating, and thinking

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Taking Notes?

One word: ENGAGEMENT

Engagement goes beyond compliance

Connection before correction


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DIR quick guide

Developmental - regulation, warm trust,

then a flow of enriching interactions

Individual Differences sensory, motor,

communication, visual-spatial, cognitive

Relationship Based connecting and

supporting at many levels

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Quality of Caregiver-Baby

Relationship Matters

D.W. Winnicott

There is no such thing as a baby

A baby cannot exist alone, but is essentially part

of a relationship

Relationships are central to development


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Affect = Emotional

Connection The glue that organizes all of the jobs

of the brain

Coordinates the nervous system from

the brain outward

Lends purpose and meaning to the

information we take in through our

senses Emotional based learning experiences

become an internal reinforcement that

motivates


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Theory Behind DIR

Affect is the central organizer ofexperience in all developmentaldomains

Experience is dual coded in the sensorysystem and the affect cueing system

Individual differences in processingsensory motor information impact how

parents and children make meaningfrom their interactions and fromexpectations about their relationships


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Individual Differences

Sensory modulation and processing

Postural control and motor planning

Receptive communication

Expressive communication

Visual-spatial funciton

Praxis: knowing how to do things to

solve the social problem of the moment


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Things to Keep in Mind

Hypo-reactive (decreased sensitivity)

Sensory seeking

Does not register input or has delayed

responsiveness to sensory input

Hyper-reactive (increased sensitivity)

Sensory avoiding

Associated with increased reactivity to

sensory input (fight/flight/fright

responses)

Mixed Hypo/Hyper-Sensitivity: common


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Caregiver Patterns and

Child Development

Sensitive responsiveness

Attunement

Mutually confirming interactions

Mirroring, Matching, Expanding

Attachment

Secure, Anxious, Avoidant, Chaotic, Aloof


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Relationship Classification

Overinvolved

Underinvolved

Anxious/Tense

Angry/Hostile

Mixed Relationship Disorder

Abusive (verbal, physical, sexual)


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More to the point:

Joint attention responsive (cured),

initiated (when we wait for it)

Intent

Engagement

Repair (Tronick)

These are at the core of the moment to

moment affective reciprocity that

supports the developing relationship.

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Functional Emotional

Developmental LevelsI co-regulation, ability to attend, interest in the world

II engagement, attachment, gleam in the eye, warmth

III circles of interaction, purposive two way

communicationIV flow, social problem solving, behavior organization

V symbolic thinking (critical shift)

VI logical connections between ideas (what, when, how,

and why questions)

VII multicausal thinking

VIII grey area thinking

IX reflective thinking, stable sense of self, and an internalstandard

I alm enough: ( o


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Know the person: individual differences

We do this together

Not a sensory break (= escape)

Reach wth 80% intensity to help theperson calm down with you.

Calm enough might mean active

enough. Think about what works and what

doesnt work

I - alm enough: ( o-regulation)


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II - Truly Connected to Others

(Engagement)

That gleam in the eye

Mostly fun and feels good for everyone

creates the bond that will leads to learning Joint attention, but joyful


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III Circles:

back and forth interaction

The person is always doing something

Follow the childs lead - Join in - be part

of the activity

Improv = yes

If you cant just join in, gently and

playfully get in the way

If he wants something, he has to get it

from you


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IVFlow

(and avoiding questions)

Chains of 20-40 circles

Expanding complextiy

Questions make people close up or act mad Statements create social problems that the

other person can solve

Try it out. Its hard, but worth the work


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Things to Avoid

Dont just entertain, quiz, or direct the childwith your games, demands, or ideas

Dont merely follow the child around use

the child lead to start off

Every idea is a good one to play with dont

say no to the idea - connect and play with it.You can set limits as needed.


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What about other kids?

Start with adults

Build some skills

Semi-structured activities with peers

Limiting numbers of kids

Mediate the process slow it down

Statements more than questions

Democratic decision making


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Things you might say or do:

We need to figure out what to do I need help with

Wait - I didnt hear you

We can vote on whether he was out.. Semi-structured: at times you direct things,

but work toward less of it.

In free play, you join the person in a way thatattracts other kids, then facilitate the mix


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Likert Scale for Each Level

1. Not doing it

2. Barely able to do it

3. Islands of time where the child can do it

4. Can expand those islands with our help

5. Comes back for more with little or no

support

6. Pretty normal unless under stress

7. Age appropriate


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Family /Caregiver Patterns:

Comforting

Finds appropriate level of stimulation

Engages in relationship Reads cues and signals

Maintains affective flow (for co-

regulation) Encourages development


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The Learning Tree

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Summary: Why DIR?

It is BPS, and BPS is good

We can change outcomes despite genetics.

Affect is the key - this is affect based

Beyond behavioral treatments

Medication can only support treatment

There is Evidenced Based Research to

support it


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Research Support for DIR/Floortime

Macro: comprehensive interventions

Odom, et al. there is no one winner..Care reports, single case studies

Salt, Mahoney

PLAYPajareya

York

Micro: core conceptsJoint attention

Parent coaching

Repair 40


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Evidence based medicine,

and informed consent

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Reflective Process

There are always new challenges

Nothing goes as expected

Caregivers rarely have the supportand time they need to think

Make time a moment to l isten.

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R fl ti P


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Reflective Process:

in the moment Humility: you do not have the

answer

Facilitate problem solving

Wonder about the situation

Track the emotion, then and now

Statements vs. questions. Empowering vs. dictating.

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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.

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Medications

Rationale for using medication: last

resort vs. covering all bases

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Controversies about medications in

developmental and learning disorders:

Stimulants

Antidepressants

core symptoms

overmedication

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Specific Medications

For details see circlestretch.com

For a framework, see The Learning Tree

(+caregiver profile)

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Remember the Tree

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Individual Differences CharliePreschool 5/05 &


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Kindergarten 9/05

Sensory Postural Response to

Communicat io

n

Intent to

Commun i

cate

Visual

Explorat ion

Praxis -

Sensory

seeking,

distractible

AuditoryVisualTactile

VestibularProprio-ceptiveTasteOdor

Low tone;A bit clumsy -

impedes rapid

reciprocity in

the moment1 indicate

desires2. mirrorgestures3. imitate

gesture

---- 05/05----4. Imitate with

purpose.

5. Obtaindesires6. interact:

- exploration- purposeful

-self help-interactions

Trouble managing

more than one

thing at a time

1. Orient2. key tones3. key gestures4. key words

---- 05/05----5. Switch auditoryattention back

and forth6. Follow

directions7. Understand

W ?s8.abstract

conversation.

Dysarthric

Logical

discourse is

Difficult

1. Mirror

vocalization

s2.. Mirrorgestures3. gestures4. sounds5.Words

---- 05/05---

6. twoword

7.Sentences

8. logical

flow.

Distractible.1.focus on object

---- 05/05----

2. Alternate gaze3. Follow

anothers gaze todetermine intent.

3. Switch visualattention4. visual figure

ground5. search for

object

6. search two

areas of room7. assess space,shape and

materials.

-

Easily

frustratedIdeation-- 05/05---Planning

(including

sensory

knowledgeto do this)

Sequencin

g

Execution

Adaptation

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Individual Differences Charley First Grade


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Individual Differences CharleyFirst Grade

Sensory Postural Response to

Communicat io

n

Intent to

Commun i

cate

Visual

Explorat ion

Praxis -

Sensory

seeking,

distractible

AuditoryVisualTactile

VestibularProprio-ceptiveTasteOdor

Taste and

odor are

better

Low tone;A bit clumsy -

impedes rapid

reciprocity in

the moment1 indicate

desires2. mirrorgestures3. imitate

gesture4. Imitate with

purpose.

----3/07----5. Obtain

desires6. interact:

- exploration- purposeful

-self help

-interactions

Much betterpostural control

Trouble managing

more than one

thing at a time

1. Orient2. key tones3. key gestures4. key words

----3/07----5. Switch auditoryattention back

and forth6. Follow

directions7. Understand

W ?s

8.abstract

conversation.

Stronger foundation

Dysarthric

Logical

discourse is

Difficult

1. Mirror

vocalization

s2.. Mirrorgestures3. gestures4. sounds5.words

----3/07----6. twoword

7.Sentences

8. logical

flow.

NOT

CHANGED

Distractible.1.focus on object

2.----3/07----2. Alternate gaze3. Follow

anothers gaze todetermine intent.

3. Switch visualattention4. visual figure

ground5. search for

object

6. search two

areas of room7. assess space,shape and

materials.

Can focus pretty

well on an object

now

Easily

frustratedIdeationPlanning

(including

sensory

knowledgeto do this)

----3/07----Sequencin

g

Execution

Adaptation

A step

forward..

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Sample Full FEDL (Charlie)

Not there Barely Islands Expands Comesback

Ok if notstressed

Ok forage

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, 3/0953

R l ti hi C i P fil


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Relationships - Caregiver Profiles:

Not yet able

to support

Just starting

to support

Islands of

support

Moderately

effective in

supporting

50%

Becoming

consistent

in ability

to support

Effective

except

when

stressed

Very

Effective in

supporting

Comforting

the child

Finding

appropriate

level of

stimulation

Pleasurably

engages the

child

Reads

childs

emotional

signals

Responds

to childs

emotionalsignals

Tends to

encourage

the child

]

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Relationships - Caregiver Profiles: first grade teacher,


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p g g ,

aide

Not yet able

to support

Just starting

to support

Islands of

support

Moderately

effective in

supporting

50%

Becoming

consistent

in ability

to support

Effective

except

when

stressed

Very

Effective in

supporting

Comforting

the child

Not fuzzy,

but not

reactive

mellow

Finding

appropriate

level of

stimulation

directive unflappable

Pleasurablyengages the

child

directive Persistentattempts to

engage him

Reads

childs

emotional

signals

Sees when he is

upset

Can predict

when he will

become

upset

Respondsto childs

emotionalsignals

Unsure what to do Interested in theflow of activity,

not interaction

Tends to

encourage

the child

directive Wants him

regulated so

he can learn

(not interact

per se)

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Relationships - Caregiver Profiles: second grade


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p g g

teacher, resource teacher, aide

Not yet able

to support

Just starting

to support

Islands of

support

Moderately

effective in

supporting

50%

Becoming

consistent

in ability

to support

Effective

except

when

stressed

Very

Effective in

supporting

Comforting

the child

Kind and

clearmellow

Really there

for him, can

help him

settle

Finding

appropriate

level of

stimulation

directive Pretty good with

him

Calm and

positive, able

to flexibly

shift level ofstimulation

Pleasurably

engages the

child

directive Learning to

engage

Some nice

non-verbal

flow

Reads

childs

emotionalsignals

Predict when

he is upset

Tries hard to do

this in the

moment

Naturally

reads his

cues

Responds

to childsemotional

signals

Still unsure what to

do

Interested in the

flow ofinteraction

Naturally

responds

Tends to

encourage

the child

Still directive Strong desire

to see him

regulated and

engaged

Regulated for

interaction;

coaches

aides, staff

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Medications Approved by the


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Medications Approved by the

FDA for Marketing for the

Treatment of Autism

Risperdal - 10/06 - Irritability

Abilify - 11/09 Irritability

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Thanks and Have a Good


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Thanks and Have a Good

Day!

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Ok, theres more to it

Are medications a good thing?

Medical Ethics

FDA

Evidence Based Medicine

Informed Consent

Family

How Doctors Think

Medications and medication options

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Its complex

People like things simple and practical

This is not simple

But if you follow along, it can be quite

helpful and practical.

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Good Medicine

Good = it might help (help what?) -

beneficence

Good = it wont cause bad side effects -

Do No Harmnon-maleficence

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4 Main Principles of Medical Ethics*

1. Beneficence doing good (EvidenceBased Medicine)

2. Non-maleficence risk vs. benefit(Do No Harm)

3. Autonomy informed consentwithout 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.

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History of Trying to do Good

Food and Drug Act of 1906 safe

medicines, not diet pills from tapeworm

eggs

Flexner Report on Medical Education1910 medical care has risks and so

medical education requires standards

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The FDA

Approves medication for marketing for

specific symptoms of specific conditions

Allows doctors to use medications for

whatever they think is appropriate

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FDA Approval


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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

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Its 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

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New approaches:


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pp

CAPTNChild & Adolescent PsychiatryTrials Network

NIH / Duke

Efficiency Studies

Pharmacogenetics

Results pending

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The upshot for the


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The upshot, for the

moment

Companies seek FDA approval is for

BIG MARKETS

Most psychiatric medication for kids is

experimental

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Doctors Need:

To know a lot

Respect for troubleSteady care

Judgment & Experience

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Clinical Judgment & Experience


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g p

with

the condition

the medications

otherneurobehavioral and medical

conditions

side effects & drug interactions

the terrible things

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Doctors Experience

Often limited

In my experience = seen one

In a series = seen two

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Terrible Things

Morbidity severe side effects (e.g. hepatic

failure, NMS, TD, etc. etc.)

Mortality

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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

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Family Choice

For lifelong challenges

Severe symptoms and impact

Families must know their options

Family circumstances and values arepreeminent

Hope is essential - unfounded hope is cruel

Family choice is the heart informed consent

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Diagnosis

Target Symptoms Treatment Protocol

Alternative Treatments

Results of No Treatment Side Effects

FDA Labeling: experimental

Consent & Assent

Comments, Questions & Concerns: trackclosely

INFORMED CONSENT IS A PROCESS75


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So why use meds?

Can help, sometimes dramatically

Duty to Inform

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Good information is part of


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Good information is part of

good medical care

Could help, and perhaps

avoid harm

Standard of care

Practice guidelines

Evidence Based Medicine

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E id d B d M di i


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Evidenced Based Medicine

Sackett, et. al. British Medical Journal1996;312:71-72 (13 January)

the conscientious, explicit, and

judicious use of current best evidence inmaking decisions about the care of

individual patients.

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M i h t?


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Meaning what?

integrating clinical expertise withsystematic studies

consideration of clinically relevant

research and respect for the individuals

predicament, rights, and preferences

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Misuse of Evidence Based Medicine

Cost cuttersno research

Vested Interestsonly our

research counts

Convinced Cliniciansmy

experience is what matters

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G ld St d d E id


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Gold Standard Evidence

Double Blind

Placebo (or wait list) Controlled

ProspectiveRandomized

Multiple Subjects

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M di i T d


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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)

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A d P l H


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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

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S EBM i


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So EBM requires:

Currentbest evidence

Clinical expertise & judgment

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E id Ch O Ti


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Evidence Changes Over Time

Half changes every 5 years

50% is wrong

We dont which half

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Find one you can work with

Keep the doctor informed about whatis happening with meds and therapy

Dont overwhelm with data

Doctors can be confused

(

biomedical

)Respectfully offer resources

Good doctor consult other doctors

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Competence: APBN Board

Certified

Ethics: AACAP = try their best

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Th R l f M di ti


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The Role of Medication

Overview

Progress?

A Good Enough ProgramA General Approach to

Medication

Gridding the Problem

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1989 Magda Campbell: haloperidol helps

social learning; others: methylphenidatecauses side effects without benefit.

1990s - 2006: treating target symptoms,based on responses in other conditions to

medications; lots of use of neuroleptics foraggression, etc.

2004 Black Box warning for SSRIs in kids

2006 Risperdal

Early 2009 Celexa not working for OCDin ASD

Late 2009 Abilify

2010 Cochrane report on SSRIs and autism89


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Most people consider meds because

they feel stuck, maybe desperate

Emergencies: aggression, depression,others?

Lack of progress

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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.

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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

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Are we asking too much of a child?

Of a family? Of a school?

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The Central Question


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The Central Question

Are you trying to improve an appropriate

situation or make up for a bad one?

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Will they change my childs brain and fix it?

Could they injure my child? What should I expect?

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To avoid losing time while pulling the

program together To do as much as possible

Awakenings are we trying for a miracle?

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Cant guarantee results

If no emergency, theres time

When parents disagree

Side effects

Treatment teams

all about the meds

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Complete workup a must: consider (24 hour) EEG, labs, etc.along with complete history, physical, t ime with the chi ld and fami ly, andcollateral information from school, therapists, etc.

Diagnosis: a hypothesis meant to focus treatment, as well as otherpossible & co-occurring diagnoses. The 5 axis system helps, and new dimensionalaxes may work better

Grid and prioritize target symptoms andpossible treatments and fill in likely +s & -s, in a flexible decision matrix Availability- doctor MUST stay in touc hwith family and school

GOLDEN RULE: think carefully before rapid,large changes in dose or before changing

more thing than one thing at a time.

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Gridding Target Symptoms


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Gridding Target Symptoms

Target symptoms

Prioritizing Symptoms

Core Symptoms

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Name Your Symptoms


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Name Your Symptoms

Activity,impulsivity

Anger Attention

Anxiety,specificfears

Cognition

Depression GI Distress Mood

instability,irritability,aggression

Motor Planning O/C,

rigidityPerseverati

ve Pain Reciprocal

interaction Seizures Sensory

Sensitivity

&Processing

Sleep Tics

Others??

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Targe

ts

Activity

Atten

tion

Anxie

ty

Cogn

ition

Depression

Mood

Instability

aggression

Motor

Plann

ing

O/C,rigidity

Perse

verative

Recip

rocal

intera

ction

Sensory

Sensitivity

Tics

Sleep

Etc

Comments

Stimulants +/- +/- - +/- - - +/- - +? - - - Wt

Ht

tics

SSRIs - - +/- -/+ +? -/+ +? +? -/+ Wt, Ht

Sz

Neuroleptics +? -? + -/+ +? ++? - +? ++?? +? + + Wt. Sz

TD

NMS

AEDs +? -/+ + -

/+?

+? ++? -? +? +? +? +

?

+/- Mult.

SE

Steroids -? -? +? +? -/+ -? +? -? ++? -? +

?

-? Mult

SE

Central Alpha

Agonists

+? +? +? -/+ +/- 1/+? -/+? +? +? +? +

?

+ Sleep

BP

Etc

LIST OTHER

TREATMENTS!

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Core Symptoms?


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Core Symptoms?

Relating

Communicating

Healthy development: connected, regulated

emotions that breathe life into adaptive thinking

and planning

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Support regulation and co-regulation bytreating, e.g., impulsivity, inattention, anxiety, rigid thinking,perseveration.

Widen tolerance of emotions sothe person is less likely to become overwhelmed.

Treat co-occurring conditions,e.g., depression.

Mightpromote abstractreasoning and thinking.

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The Bottom Line:


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The Bottom Line:

medication probably does not treat coresymptoms 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.

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Specific Psychotropic


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Medications

Try to always know the brand andgeneric names of medications

Rxlist.com is often helpful

The following list and the informationprovided is not comprehensive; please

talk with your own health care provider

for further information

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Stimulants


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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.

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SSRIs


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SSRIs

One of many classes ofantidepressants

Can really help depressed mood, maybe anxiety,less likely obsessiveness (although works well forthat forneurotypicals)

Prozac (fluoxteine), Zoloft (sertraline), Paxil

(paroxetine), Luvox (fluvoxamine), Celexa &Lexapro (citalopram).

Similar possible side effects: behavioralactivation, weight gain (and loss), mood instability,lower seizure threshold, etc.

Black box warning about suicidal thinking vs. lowerrates of actual suicide in people treated withSSRIs

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Neuroleptics


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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.?

Side effects can include weight, lipid, and sugar issues,

as well as seizures, fevers (NMS) and new abnormalmovements (TD), stroke (elderly), cardiac

Should we always consider neuroleptics?

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AEDs


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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


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Specific AEDs

Depakote (valproic acid, valproate) prettyreliable, 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

?; motorproblems, electrolyte issues, rash?

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More AEDs


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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

Topamax (topiramate) adjunct, may cause weight

loss, loss of expressive language, usually need to goslow.

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

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Steroids


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Steroids

LKS variant theory epileptic aphasia 24 hrEEGs

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

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Central Alpha Agonists


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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

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Other Commonly Considered


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Medications

Straterra (atamoxetine) for ADHD; may be asgood as placebo, may act like an antidepressant(+/-)

Wellbutrin (bupropion, etc.) dopaminergic,weight, loss, sleep loss, irritability, seiaure risk

Rozerem (ramelteon) melatonin agonist

SNRIs Effexor (venlafaxine), Cymbalta(duloxetine), Remeron (mirtazepine), Serzone(nefazedone), Pristique (desvenlafaxine).

Deseryl (trazodone) antidepressant often usedfor sleep; cognitive side effects, priapism

Buspar (an azaspirone) mild, serotonergic crossreactions

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More Others


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More Others

Lithium great mood stabilizer; anti-suicidal; bipolar-ASD connection; levels,

thyroid, kidney function

Namenda (memantine) Alzheimers med

antagonistof the N-methylD-aspartic

acid (NMDA) glutamate receptor, thisdrug

was hypothesized to potentially modulate

learning, block

excessive glutamate effectsthat can include neuroinflammatoryactivity,

and influence neuroglial activity in autism

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Meds that I often avoid


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Meds that I often avoid

Paxil (paroxetine), Effexor (venlafaxine), Cymbalta(duloxetine) - withdrawal

Tegretol (carbemazepine) hard to make it work

Combo Depakote and Lamictal

Tricyclics Tofranil (imipramine), Norpramin

(desipramine), Pamelor (nortriptyline); and, esp. goodfor typical OCD, Anafranil (clomipramine). Cardiac andblood 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 beconsidered; lots of drug-drug interactions

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Special Caution on

B di i !


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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

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Targets

Activ

ity

Atten

tion

Anxiety

Cogn

ition

Depr

ession

Mood

Insta

bility

agg

ression

Moto

r

Planning

O/C,

rigidity

Perseverative

Reciprocal

interaction

Sens

ory

Sens

itivity

Tics

Sleep

Etc

Com

ments

Stimulants +/- +/- - +/- - - +/- - +? - - - Wt

Ht

tics

SSRIs - - +/- -/+ +? -/+ +? +? -/+ Wt, Ht

Sz

Neuroleptics +? -? + -/+ +? ++? - +? ++?? +? + + Wt. Sz

TD

NMS

AEDs +? -/+ + -

/+?

+? ++? -? +? +? +? +

?

+/- Mult.

SE

Steroids -? -? +? +? -/+ -? +? -? ++? -? +

?

-? Mult

SE

Central Alpha

Agonists

+? +? +? -/+ +/- 1/+? -/+? +? +? +? +

?

+ Sleep

BP

Etc

LIST OTHER

TREATMENTS!

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Getting back to the tree


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Getting back to the tree

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Targets

Sens

ory

Proc

essing

Moto

rtone

andmotor

Planning

Rece

ptive

Com

municatio

n Expr

essive

Com

municatio

n VisualSpatial

Prax

is

Othe

rmedical

Etc

Com

ments

Stimulants -/+? -/+? -/+? -/+? -/+? -/+? -/+? WtHt

tics

SSRIs Wt, Ht

Sz

Neuroleptics Wt. SzTD

NMS

AEDs Mult.

SE

Steroids Mult

SE

Central Alpha

Agonists

Sleep

BP

Etc

LIST OTHER

TREATMENTS!

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Targets

Co-regulation

Enga

gement

Circles

Flow

Symbolic

Logical

Multicausal

Nuan

ce

Refle

ctive

Num

ber10?

Etc

Com

ments

Stimulants Wt

Ht

tics

SSRIs Wt, Ht

Sz


NMS

AEDs Mult.

SE

Steroids Mult

SE

Central Alpha

Agonists

Sleep

BP

Etc

LIST OTHER

TREATMENTS!

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Targ

ets

Rea

ding..

Writing

Arithmetic.

Ethicalrules

Trad

eskills

Swimming.

Etc

Com

ments

Stimulants Wt

Ht

tics

SSRIs Wt, Ht

Sz


NMS

AEDs Mult.

SE

Steroids Mult SE

Central Alpha

Agonists

Sleep

BP

Etc

LIST OTHER

TREATMENTS!

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Targets

Com

forting

thec

hild

Findingan

appr

opriate

levelof

stimulation

Pleasurable

enga

gingthe

child

Read

ingthe

child

s

emotional

signals

Resp

ondingto

thec

hilds

emotional

signals

Enco

uraging

thec

hilds

deve

lopment

Etc

Com

ments

Stimulants Wt

Ht

tics

SSRIs Wt, Ht

Sz


NMS

AEDs Mult.

SE

Steroids Mult

SE

Central Alpha

Agonists

Sleep

BP

Etc

LIST OTHER

TREATMENTS!

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124

Abnormal Involuntary Movement Scale (AIMS)


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125


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Look at the whole picture, and reflect

Be careful with meds Engage the Child

Your Experiences?

126

Never g ive up , neversurrender!


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- Captain Peter Quincy TaggartCommander, NSEA Protector

Medication Support for DIR Programs October 28 2011 Tel Aviv

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Transcript of Medication Support for DIR Programs October 28 2011 Tel Aviv