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AnaheimFebruary, 2010
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Go Bolts!
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Assistant Clinical Professor,
Dept of Psychiatry, University ofCalifornia at San Diego School of
Medicine
Faculty, Interdisciplinary Council onDevelopmental and Learning
Disorders
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ICDL Faculty minimal - review of clinical write ups,travel and room for meetings, token honorarium for co-
writing and running Southern California Institute
NIMH/ Duke University minimal administrative time forpharmacogenetic research
NIH R21 grant/ San Diego BRIDGE Collaborative minimal token honorarium for ongoing consultationand participation
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Feder 411
1980 BU: math and Mass Assn for the Blind
1990 Hawaii: Bernie Lee
1992 Matt
1993 - DC: Greenspan, Wieder, et. al.
1996 San Diego: neurobehavioral -psychiatric
2010 ICDL, SDPS Ethics, BRIDGE, CAPTN,SCART
(etc: dance, engineering)
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The Autism File: Becoming MoreMatthew January 2009
Traditional Intervention: ABA really worked and metgoals: he learned to sit
Traditional Medicine indispensible to success
Family therapy time to step back and reflect
SL - long term, wonderful engaging relationships SIOT ah ha!: let him stand, big activity, etc.
Nutrition, VT, Tomatis, dogs, dolphins..
DIR/Floortime really worked and met goals: helearned to survive
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This is not a DIR/Floortimetalk
And my kid is not your kid
but context is important
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DIR
Broad whole child, supports family
Welcoming all about building love
Enriching closeness can bringprogress
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DIR in a nutshell
Developmental levels fromregulation, to warm trust, and then aflow of enriching interactions
Individual Differences sensory,motor, communication, visual-spatial,cognitive, etc.
Relationship Based all aboutconnecting, and making time withothers for support and help
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To learn more onDIR/Floortime
Icdl.com free podcasts anddownloads
Circlestretch.com San Diegoregional website
Pasadena 2/13/10 PasadenaChild Development Associates
Free community support groups
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Considering medication
Case examples
Your experiences
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FDA Approved Medications
for the Treatment of Autism
Risperdal - 10/06 - irritability associated withautistic disorder, including symptoms of aggression,deliberate self-injury, temper tantrums, and quicklychanging moods, in children and adolescents aged 5 to16 years.
Abilify - 11/09 - irritability associated withautistic disorder in pediatric patients ages 6 to 17 years,including symptoms of aggression towards others,deliberate self-injuriousness, temper tantrums, andquickly changing moods.
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Thanks and Goodnight
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Good Medicine
Good = it might help (help what?) -beneficence
Good = it wont cause bad sideeffects - Do No Harm non-maleficence
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4 Main Principles of MedicalEthics*
1. Beneficence doing good (and how do we know it might be good?Evidence based medicine)
2. Non-maleficence risk vs. benefit
3. Autonomy letting the patient (or a family) make decisions. Requiresinformed consent, no deception, confidentiality, good communication
4. Justice whats the right thing to do? fairness, equality, e.g., equal
access to services and resources, allocation of resources competingmorals: treat everyone the same? Or give people with more needsmore care? Wise use of resources, respecting individual and familychoices, respect for morally accepted laws (e.g. child abuse 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 safemedicines, not diet pills fromtapeworm eggs
Flexner Report on Medical Education1910 medical care has risks and somedical education requires
standards
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The FDA
Approves medication for marketingfor specific symptoms of specificconditions
Allows doctors to use medications forwhatever they think is appropriate
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FDA Approvalof a Medicine for Marketing
Requires studies showing it works forsome 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 inKids with ASDs
Kids are hard to find Kids have multiple diagnoses
Kids with Autism are a very mixed
group
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New studies.
NIH Duke U CAPTN ASK-PARCA
Efficiency Studies (vs. EfficacyStudies)
Pharmacogenetics
But these are few and results are
pending
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The upshot.
Once a medication is approved, it is unlikelythat a drug company will pursue otherapproval for specific uses, unless there is a
big market that will offset the costs ofresearch and the approval process
Most psychiatric medication for kids does nothave FDA approval for marketing and is
officially experimental
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In the meantimedoctors prescribe, with, we
hope:
adequate education (about grade 26) respect for serious illness, side effects, and
drug interactions
steady care
clinical judgment, based on clinicalexperience
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Clinical JudgmentDoctors have to make rational guesses based
on
Experience with the condition
Experience with the medications
Experience with otherneurobehavioral and
medical conditions (and so less likely to misssomething important)
Experience with side effects, drug interactions
Experience with the terrible things
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Doctors Experience
Often limited
In my experience = seen one
In a series = seen two
ut octors o ave
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ut octors o aveExperience with Terrible
Things Morbidity severe side effects (e.g.
hepatic failure, etc. etc.)
Mortality
House of God: Did you give him roids?
Doctors, if anyone, should know from
experience that we need to avoidtrouble
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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 a condition that is likely to present lifelong challenges
Especially one that has severe symptoms and impact
We must defend the right of families to know about their options
And give them a reasonable choice about what they want to do, based onfamily culture and values
Family circumstances and family values are preeminent in this situations.For some families meds are a last resort, and for others it seems wrong towithhold them.
Medications can give hope - essential to survive the journey - yet givingunfounded hope is cruel
Family choice is the heart of truly informed consent
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DIAGNOSIS:
TARGET SYMPTOMS:
TREATMENT PROTOCOL: ALTERNATIVE TREATMENTS DISCUSSED:
POSSIBLE RESULTS OF NO TREATMENT:
SIDE EFFECTS DISCUSSED:
FDA LABELING DISCUSSED: nearly everything is experimental
CONSENT AND ASSENT DISCUSSED: COMMENTS/QUESTIONS/CONCERNS: we have to track this fairly
closely
INFORMED CONSENT IS AN ONGOING PROCESS
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With so much to consider,why use meds at all?
Medication helps many kids, sometimesdramatically
Moreover, doctors may be duty bound todiscuss meds, even if most are notFDAapproved for use for kids, for ASDs, or forcertain symptoms of ASDs
Information on medication for autism is partof good medical care
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Good information is part ofgood medical care
Failure to consider medication may rob families ofchoices that could help, and perhaps allow harmthat could have been avoided.
So people try to define the standard of care,
developing practice guidelines
Hence the focus these days on Evidence BasedMedicine
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Evidenced Based Medicine
Sackett, et. al. British Medical Journal1996;312:71-72 (13 January)
the conscientious, explicit, andjudicious use of current bestevidence in making decisions aboutthe care of individual patients.
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Meaning what?
integrating clinical expertise withsystematic studies
consideration of clinically relevantresearch
and respect for the individualspredicament, rights, and preferences
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Misuse
the Concept of Evidence Based
Medicine Cost cutters e.g. insurance companies, schooldistricts, government
Clinical medicine is driven by patient and familyconcerns
For example, the recent mammographyrecommendations which were roundly rejected inthe world of clinical medicine.
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We Would LikeGold Standard Evidence
Randomized trials and systematic reviews ofrandomized trials, are the gold standard
Double Blind Placebo (or wait list) Controlled,prospective, randomized studies, with enough
subjects to have the statistical power and a welldefined population of subjects to find outsomething meaningful
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Less than perfect is thenorm
Some questions about treatment cannot be ethically studiedwith randomized trials, e.g., grave conditions that cannot waitfor such trials to be conducted.
We must look at the evidence we do have to guide clinicalcare.
Often from other populations (e.g. age, gender, level ofchallenges), disorders with similar symptoms (OCD,depression).
It is easy to have narrow or emotional reasoning, placeboeffects
References: How Doctors Think Groopman; Science and Fictionin Autism Schreibman; Lies, Damn Lies, and Science Seethaler
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EBM is a tricky combination:
We need current best evidence,otherwise medical practice is out of date.
We need good clinical expertise and
judgment, for even excellent externalevidence may be inapplicable to orinappropriate for an individual patient.
E id Ch O
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Evidence Changes OverTime -
Five Year Half-Life.
Half of medical knowledge changesevery 5 years
So 50% of what we know is wrong
And we dont which half
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Find a doctor you like and can work with
Keep the doctor in the loop doctor must have
data Dont overwhelm the doctor with data
Doctors can be confused with terms likebiomedical
Respectfully offer resources dont expect yourdoctor to read a book for you, but do expect yourdoctor is interested in other opinions from otherdoctors
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Look for Basic Competence: APBN BoardCertified Child and Adolescent Psychiatristswere checked for competence in assessingautism, and for use of collateral information
from family, school, and other professionals.
Look for Honesty: AACAP = a promise to beethical and do their best
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The Role of Medication
Overview
Progress?
A Good Enough Program
A General Approach to Medication Gridding the Problem
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1989 Magda Campbell: haloperidol helps social learning; others:methylphenidate causes 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 OCD in ASD
Late 2009 - Abilify
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Most people consider meds becausethey 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 motorfunction
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
Are you trying to improve an
appropriate situation or make up fora 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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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
Side effects e.g., behavioral activation (SSRIs), increasedperseveration (stimulants), sedation (some anticonvulsants,others).
Treatment teams often overuse medications, ignoringengagement, other factors.
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Complete workup a must: consider (24 hour) EEG, labs, etc. alongwith 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 asother possible & co-occurring diagnoses. The 5 axis systemhelps, and new dimensional axes may work better
Grid and prioritize target symptoms and possible treatments andfill in likely +s & -s, in a flexible decision matrix
Availability - doctor MUST stay in touch with family and school
Think carefully before rapid, large changesin dose or before changing more thing than
one thing at a time.
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The Bottom Line:
medication probably does not treatcore symptoms, but might makesome target symptoms or co-
occurring conditions better, creatingmore affective availability so that wecan make progress, if you can avoid
significant side effects.
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Gridding Target Symptoms
Target symptoms Prioritizing Symptoms
Core Symptoms
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Name Your Symptoms
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Core Symptoms?
Relating
Communicating
Healthy development: connected, regulated
emotions that breathe life into adaptivethinking and planning
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Support regulation and co-regulation bytreating, e.g., impulsivity, inattention,
anxiety, rigid thinking, perseveration. Widen tolerance of emotions so the
person is less likely to becomeoverwhelmed.
Treat co-occurring conditions, e.g.,depression.
Might promote abstract reasoning and
thinking.
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Specific Psychotropic
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Specific PsychotropicMedications
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
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
One of many classes of antidepressants
Can really help depressed mood, maybe anxiety, less likelyobsessiveness (although works well for that for neurotypicals)
Prozac (fluoxteine), Zoloft (sertraline), Paxil (paroxetine), Luvox(fluvoxamine), Celexa & Lexapro (citalopram).
Similar possible side effects: behavioral activation, weightgain (and loss), mood instability, lower seizure threshold, etc.
Black box warning about suicidal thinking vs. lower rates ofactual suicide in people treated with SSRIs
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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 ofpsychosis.
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 asseizures, fevers (NMS) and new abnormal movements (TD), stroke(elderly), cardiac
Should we always consider neuroleptics?
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AEDs
Anti-Epileptic Drugs (aka anti-seizuremedications)
So many and all so different in character
For seizures, and for mood stabilization
Might help other medications work better(stimulants, antidepressants)
Combined pharmacology vs. polypharmacy
Sudden sopping might make seizures more likely
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Specific AEDs
Depakote (valproic acid, valproate) prettyreliable, easy to load, watch levels, platelets,bruising, liver, pancreas, carnitine, menstrualirregularities, weight, sedation. Problems when
using with Lamictal Tegretol (carbemazepine) - ?reliable, watch
levels, blood counts, EKG, lots of druginteractions, weight gain, sedation, rash
Trileptal (oxycarbezine) Tegretol light?; motorproblems, 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 goslow, and watch for rash
Topamax (topiramate) adjunct, may cause weight loss, loss ofexpressive language, usually need to go slow.
Neurontin (gabapentin) Does it work at all? Does it harm atall? Does help pain syndromes.
Lyrica (pregabalin) for pain in fibromyalgia, partial seizures
Zarontin (ethosuccimide) for partial/ absence seizures; liverissues
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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, moodinstability including depression and hypomania
Pulsed dosing regimens
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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
Other Commonly
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Other CommonlyConsidered Medications
Straterra (atamoxetine) for ADHD; may be as good asplacebo, may act like an antidepressant (+/-)
Wellbutrin (bupropion, etc.) -
Rozerem (ramelteon) melatonin agonist
SNRIs Effexor (venlafaxine), Cymbalta (duloxetine),Remeron (mirtazepine), Serzone (nefazedone)
Deseryl (trazodone) antidepressant often used for sleep;cognitive side effects, priapism
Buspar (an azaspirone) mild, serotonergic cross reactions
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More Others
Lithium great mood stabilizer; anti-suicidal;bipolar-ASD connection; levels, thyroid, kidneyfunction
Namenda (memantine) Alzheimers med
antagonistof the N-methylD-aspartic acid(NMDA) glutamate receptor, thisdrug washypothesized to potentially modulate learning,blockexcessive glutamate effects that can
include neuroinflammatoryactivity, andinfluence neuroglial activity in autism
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Meds that I often avoid
Paxil (paroxetine) - withdrawal
Effexor (venlafaxine) - withdrawal
Tegretol (carbemazepine) hard to make it work
Combo Depakote and Lamictal
Tricyclics Tofranil (imipramine), Norpramin (desipramine), Pamelor(nortriptyline); and, esp. good for typical OCD, Anafranil (clomipramine).
Cardiac and blood pressure issues.
Monoamine Oxidase Inhibitors Nardil (phenelzine) , Parnate(tranylcypromine), Marplan (isocarboxazide), Emsam (selegiline) can beuseful although dietary, blood pressure drop and hypertensive crisis must beconsidered; lots of drug-drug interactions
Special Caution on
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Special Caution onBenzodiazepines!
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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Ok early history 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 lots of behavioral and language services.
medical: ?seizures, allergies to eggs, peanuts, amox, eczema
*All names and identifying information have been changed
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?Meds for anxiety in autism, Jan 2008
Failure to make gains despitemassive services
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Autism SAFETY fingers in eyes extremely perseverative (fans)
anxiety over-activity tantrums language
hard to take him out ?seizures.
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Mar 08: break the door MOV00732.MPG(0:10)
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So what meds might we
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So what meds might weconsider?
Autism SAFETY fingers in eyes
extremely perseverative (fans, lightswitches)
anxiety over-activity
tantrums
language
hard to take him out in public ?seizures.
M di i
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Medications:
Trileptal, EEG improved
Spring 08 Citalopram at 10 mg helpsanxiety and a bit with perseveration
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Sept 08: Malingo Toya song and dance(0:55)
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F d f it t
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Feder favorite toys
M M di ti
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More Medication
Fall 08 Metadate CD 15 mg.
Vid
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Video
Mar 09: This Little Piggy (4:50)
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Sensory
Postural Response toCommunication
Intent toCommunicate
VisualExploration
Praxis -
Sensoryseeking,distractible
Auditory
Visual
Tactile
Vestibular
Proprio-ceptive
Taste
Odor
Best when core issupported
1 indicatedesires
----3/08----
2. mirrorgestures
3. imitategesture
4. Imitate withpurpose.
----9/08----5. Obtain desires6. interact:- exploration-purposeful
----3/09----
- self help-interactions
Cues intoimportant words
1.Orient
----3/08----
2. key tones3. key gestures
4. key words
----9/08----5. Switch auditoryattention back and
forth6. Followdirections7. UnderstandW ?s
----3/09----8.abstractconversation.
Oftenunintelligible
1.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 atdistance; fingers in
eyes; rare gleam
1.focus onobject
----3/08----
2. Alternategaze3. Followanothers gazeto determineintent.3. Switch visualattention
----9/08----4. visual figureground5. search forobject
----3/09----6. search twoareas of room
7. assess
Perseverativeideas; canexpand w/support
Ideation----3/08----
Planning(includingsensoryknowledge todo this)----9/08----
Sequencing
----3/09----
Execution
Adaptation
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Learned to quiz him, and quizzing him
Can engage in some back and forth, coachable
Discomfort with him in public so different fromother kids - improving
Stress: eye issue harrowing, but improving as hebecomes more connected.
MANY OF OUR FAMILIES HAVE A FORM OF PTSD!
Video
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Video
July 09 a whiff of symbolic capacity
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What works: playfully getting in his way, modifyinghis ideas to make them mutual (e.g. run to fan become achase and crash into couch, fan obsession becomes fanninghim), getting him on his back, extending his ideas with funengagement (piggy, dollhouse)
What didnt work: quizzing him on facts, addingideas too quickly
Medications have been very helpful to this child,allowing him to respond to developmentally supportiveintervention.
Another Case Example: T
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Another Case Example: T
Severe Dysregulation andAggression
About T :
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cute but very challenged little girl
failure to develop language, motor skills.
multiple medications, with side effects:
sedation, staggering, trouble swallowing,bruising
ABA - DTT
Miller Method
DIR
Medications for T:Combined Pharmacotherap
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Combined Pharmacotherapyvs. Polypharmacy
Depakote Carnitor
Seroquel
Trileptal
Thyroxin
Keppra
Lithium
Lamictal (Prior history of many others including
Namenda, other neuroleptics, etc.)
Video clips
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Video clips
Clip 1: 04/08
Clip 2: 08/08
Clip 3: 12/08
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Modest Improvement Over
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pTime
4 could sit a bit, give me a rare glance,take off my post-its on occasion
8 moments of gleam and a couple of
circles when I swipe her things 12 more attached to the book, and I am
able to use it as leverage for moreengagement, many circles, and the bare
beginnings of flow, no real sense ofsymbolic (but worth a try)
FEDL T
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FEDL - T1 (not
there)
2 (barely) 3 (islands) 4 (ok w/
support)
5 (comes
back)
6 (ok
unlessstress)
7 (ok)
Regulate 4 8 12
Engage 4 8 12
Circles 4 8 12
Flow 4
8
12
Symbols 4
8
Individual Differences - T
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Sensory
Postural Response toCommunication
Intent toCommunicate
VisualExploration
Praxis -
Sensoryseeking
AuditoryVisualTactileVestibularProprio-
ceptiveTasteOdor
Unstable, madeworse by meds
1 indicatedesires2. mirrorgestures
3. imitategesture4. Imitate withpurpose.5. Obtain desires6. interact:- exploration- purposeful- self help
-interactions
Somecomprehension ofsharp redirection
1. Orient2. key tones
3. key gestures4. key words5. Switch auditoryattention back andforth6. Followdirections7. Understand
W ?s
8.abstractconversation.
Difficultyindicating withgesture,Dysarthric
1. Mirrorvocalizations2.. Mirrorgestures
3. gestures4. sounds5.words6. two word7. sentences8. logical flow.
A relative areaof difficulty
1. focus onobject2. Alternategaze
3. Followanothers gazeto determineintent.3. Switch visualattention4. visual figureground5. search for
object6. search twoareas of room7. assessspace,shape andmaterials.
Ideas at times,withouteffectiveplanning norsequencing
IdeationPlanning
(includingsensoryknowledge todo this)
Sequencing
Execution
Adaptation
Reflection:
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What worked: Miller Method learned some systems
ABA - content mastered, some is somewhat functional, e.g., turn the page, some is notfunctional (points to green in trials but doesnt know what it means with the book)
I can use her desire to read the book to get some lovely connected moments
She can be a bit more regulated bouncing a bit on the ottoman, steadying herself on myarm, and that seemed to help her be emotionally connected to me too
Medication: pros and cons: cant live withthem, cant live without them; ethicalconcerns about management of medicationswhen function is impossible without them but
risks are clearly present.
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About K
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About K:
Why he came to me: aggression towardpeers in private kindergarten. Removedanyway and placed in public setting.
Main symptoms: Receptive language,difficult to understand speech, reactive tobusy environments, low tone, active,impulsive, sensory seeking, rigid,
controlling, aggressive
Medication:
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Medication:
Risperdal liquid carefully titrated;works well but so hungry on it!
Abilify to try to reduce the
Risperdal load
SSRIs helped with mood, but didnot help perseveration, and created
overactivity
Course over four years: K
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Course over four years: K
11/05 Rigid, aggressive, hits in play, not really symbolic
11/06 Allows me to join his aggressive play on his team
11/07 Increased complexity of aggressive themes; able to playwith cousin and brother in water fights, facilitated bydad
11/08 Creates a dangerous race, still very controlling, but alsotorn between me and dad, and nurturing, creative &symbolic with me; able to play with cousin and brother
in games that are competitive but not overtly aggressive
5/09 Talking with me and parents about problems at school
Video
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Video
112508
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FEDL Sample Case 3
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FEDL Sample Case 31 (not
there)
2 (barely) 3 (islands) 4 (ok w/
support)
5 (comes back) 6 (ok
unlessstress)
7 (ok)
Regulate 11/05 11/06 11/07 11/08, 5/09
Engage 11/05 11/06 11/07 11/08, 5/09
Circles 11/05, 11/06 11/07 11/08 5/09
Flow 11/05 11/06, 11/07 11/08 5/09
Symbols 11/05 11/06, 11/07 11/08 5/09
Logic 11/05,11/06
11/07, 11/08 5/09
Individual Differences Sample case 3Sensor Postural Response to Intent to Visual Praxis
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Sensory
Postural Response toCommunication
Intent toCommunicate
VisualExploration
Praxis -
SensoryseekingAuditoryVisualTactileVestibularProprio-ceptiveTasteOdor
A relativestrength;A bit clumsy -impedes rapidreciprocity in themoment1 indicatedesires2. mirror
gestures3. imitategesture4. Imitate withpurpose.5. Obtain desires6. interact:- exploration- purposeful
- self help-interactions
Trouble managingmore than onething at a timeCan barely tellwhy we fight orwhat we fightaboutCant trackconceptual
discussion of thereasoning behindevents and play1. Orient2. key tones3. key gestures4. key words5. Switch auditory
attention back andforth6. Followdirections7. Understand
W ?s8.abstractconversation.
Dysarthric unintelligibleLogicaldiscourse isdifficult(e.g. atbesthedonistic:cheating getsyou
disqualified)1. Mirrorvocalizations2.. Mirrorgestures3. gestures4. sounds5.words6. two word
7. sentences8. logical flow.
A relativestrength;Frustratedlooking forthingsSome ability towork withshapes andobjects to solve
problems inplay.1. focus onobject2. Alternategaze3. Followanothers gazeto determine
intent.3. Switch visualattention4. visual figureground5. search forobject6. search twoareas of room
7. assess
Ideas becomingmore complexwith supportAdapting toproblems thatcome up (e.g.when mycharacter isinjured, faints,
etc.)IdeationPlanningSequencingExecutionAdaptation
Family:
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Family:
Dad works hard. Can facilitate kids when available. Mom can set up playdates, engage cousin. Has to work
hard to manage environment at home so that he is not incontinuing conflict with older brother.
Brother is a good guy, and tries to play with him. But noone can really keep up with him.
Mom and Dad can play in office; however life at home isbusy - hard to find time for Floortime.
Reflection:
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Reflection:
What works: office play with him and his parents to helpthem see what we can do; play dates with cousin, brother,facilitated by parents. Now we can talk too!
What doesnt work: videogames, busy environments withmany peers.
Why: He is still developing capacities for solid enoughsymbolic play to be able to engage with peers withoutbecoming aggressive. His language and also his moresubtle postural and visual challenges make it hard for himto play with peers.
Medication makes the plan possible. Without it he
is so aggressive there is no working with him.
. ser es o t ree cases ochildren with Aspergers and
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children with Aspergers and
Depression Partnering with a colleague
Aspergers and depression withsuicidal thinking a very scarycombination
2 of 3 clearly responding to SSRIs.
5 - Brief Examplelf j i h i ( )
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Self Injurious Behavior (S.I.B.)
30 year old non-verbal old Severe clawing at chest
Not sleeping
No appetite Great live-in aide
Engagement: support and expectations
What medicine might you think about?
Zyprexa
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Zyprexa
sleeping,
eating
and engagement
because he was engaged, he stopped S.I.B. cooking,
riding,
vacations
a real life
6 - Brief ExampleOC
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OCD Had come a long way before w/ biomedical
Bright but rigid, with real OCD too (e.g. germs)
Aspergers: verbalizes a lot but without connecting
Years of work to accept use of medication
But Medication (SSRI) does help OCD for him
Engagement improving, gradual insight, and improved socialfunction and reciprocal capacity
Lessons: SSRI might work for OCD and ASD, and therapy over timecan really work for ASD core
7- Brief Example:Sti 24/7
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Stims 24/7
A very active non-verbal 8 year oldboy
Strings
Not sleeping: severe impact onfamily
Medicines youd think about?
The Medication Angle
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The Medication Angle
Guanfacine worked for months Rozerem worked for months
mirtazepine - working for months
Intervention: The EngagementA l
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Angle
Joining the string thing Time, time, and more time
Eventual gleam and non-verbal
communication about it
Video
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Video
String play
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8 - Brief Example:T iti
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Transitions
60ish male, modest verbal ability Extremely anxious and reactive
Apparent PTSD + Autism
Cant stand any changes Minimally verbal
Heavy and not exercising
So medicine you might think of?
The Medication Angle
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The Medication Angle
Effexor, then reduction over years Topamax, then reduction when getting
thin
Significant improvement in anxiety Significant improvement in reactivity
Significant improvement in weight control
Significant improvement in engagability
The Engagement Angle
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The Engagement Angle
Engagement has had gradual benefit: Enjoys his meals,
Goes on camping trips
Engaging, graduated exercise Does well in an active day program
Remember routine medical care!
9- Brief example:Running Off
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Running Off
Big teen male with mood instability On 1200 Trileptal
Limited verbal ability
Inclusive high school
Urgent problem at school
What might you try?
The Medication Angle
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g
Zyprexa to Stabilize Increased the Trileptal over time
Weight gain, but cant totally stop
neuroleptics
Abilify replacing Zyprexa
NB: RSR on EKG got CardiologyConsult to think through risk ofToursades de Pointes
The Engagement Angle
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g g g
Loping after him worked really well,as long as the person was calmlyfollowing, and there was a gate
where he was running.
Video
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Tremor check
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Abnormal Involuntary Movement Scale (AIMS)
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10 - Brief Example:
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p
Young boy with autism, self injurious behavior, lowIQ and inattention; institutionalizationrecommended but family declined
Compliant, and behavioral intervention helps with
sittings and following directions Various meds tried early on, settling on
methyphenidate ( MPH, like Ritalin, etc.) forattention and central alpha agonists for tics andwithdrawal crankiness
The Engagement Angle
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g g g
Lots of intervention, at home and schoolwith everyone on the team (family, SLP,OT, ED, etc.) centered on co-regulation,engagement, and reciprocity
Inclusion* early on, with social facilitation,tutoring using his interests to scaffoldacademics
*Read Paula Kluths books e.g. Youre Goingto Love This Kid
Medication, Outcomes,and Lessons Learned
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and Lessons Learned Gradual improvement over many many years in academic
and social function, increase in testable IQ to superior ranges;ok in church groups, interest groups, ok at 4 year college(with hovering)
Academic function and success of placement absolutely
dependent on MPH. More social off of MPH, more paranoid on it, sleeps less, eats
less. But benefits outweigh risks
Try not to put a ceiling on possible progress.
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Look at the whole picture
Be careful with meds Engage the Child
Your Experiences?
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