Psychotropic Meds Asilomar

Asilomar 2009

Assistant Clinical Professor, Dept of Psychiatry, University of California at San Diego School of Medicine Faculty, Interdisciplinary Council on Developmental and Learning Disorders

The Southern California DIR®/Floortime™ Regional Institute Pasadena, California begins October, 2009 Josh Feder, MD       [email protected] [email protected] Mona Delahooke, PhD               [email protected]       

Diane Cullinane, MD

 

Pat Marquart, MFT [email protected]

ICDL Faculty – minimal - review of clinical write ups, travel and room for meetings, token honorarium for cowriting and running Southern California Institute NIMH/ Duke University – minimal – administrative time for pharmacogenetic research NIH R21 grant/ San Diego BRIDGE Collaborative – minimal – token honorarium for ongoing consultation and participation

a novella on the use of medication (20 min) brief monograph: medication from a DIR® perspective (3 min) fantasies and nightmares in med-land (2 min) the story of a real boy and a diagnostic system (20 min) your stories…(15 min)



all slides will be posted on

circlestretch.blogspot.com Stop me on the blue dots!

Quick history: Magda Campbell: haloperidol helps social learning; others: methylphenidate causes side effects without benefit.  Today: we try to treat target symptoms, carefully, based on responses in other conditions to medications.  Takes time to assess, and re-assess.  Big issues: marketing, side effects, and efficacy studies.  Efficiency study: CAPTN (Duke: John March, el al – I’m an et al…). 

Most

people consider meds because they feel stuck, maybe desperate Emergencies: aggression, depression, others? Lack of progress

 What

do we want for the child?  What is the meaning of the disability to the family and to the child?  The usual wish: a meaningful life (socially, emotionally, maybe cognitively)  Requires a plan, and medication alone is not a plan.

 regulatory

issues/ motor and sensory areas

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

Are

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

Low Support - Low Expectation

Low Support - High Expectation

(neglect…)

(‘Just do it…’)

High Support - Low Expectation

High Support - High Expectation

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

(respectful coaching)

 Is

the program adequate?  Will they change the child’s brain and actually fix it?  Will they injure the child?  What should I expect?

Losing

time while pulling the program together Doing as much as possible Awakenings – should we go for a miracle?

 We

do not know enough to say ‘you really should medicate’  If there is no emergency, you have more time to think about it  When parents differ, it can be an opportunity for more thoughtful planning

 



Are you trying to save a placement or make up for a bad one?



Are meds a last resort or is it unethical to withhold them?



Complete workup a must: consider EEG, labs, etc. along with complete history, physical, MSE, and collateral information.



Availability - doctor MUST stay in touch with family and school



Rapid, large, or multiple changes are often problematic



Grid target symptoms vs. possible meds and fill in possible +’s & -’s

Easy for the treatment team to react and overuse medications  Side effects often create significant difficulties, e.g., behavioral activation (SSRIs), increased perseveration (stimulants), sedation (some anticonvulsants, others).  Team treatment often becomes ‘all about the medication’, ignoring engagement, other factors.  Bottom line: medication probably does not treat core symptoms, but might create more affective availability, if you can avoid significant side effects. 

 elements

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

NAME: DOB: DATE:   DIAGNOSIS:   TARGET SYMPTOMS:   TREATMENT PROTOCOL:    ALTERNATIVE TREATMENTS DISCUSSED: POSSIBLE RESULTS OF NO TREATMENT: SIDE EFFECTS DISCUSSED: FDA LABELING DISCUSSED: CONSENT AND ASSENT DISCUSSED:   COMMENTS/QUESTIONS/CONCERNS:     I UNDERSTAND THIS CONSENT AND ALL HAS BEEN EXPLAINED TO ME. TREATMENT, INCLUDING USE OF MEDICATIONS IS VOLUNTARY AND I PLAN TO WORK WITH THE DOCTOR TO MAKE THE BEST USE OF THESE. I CONSENT TO THE TREATMENT. IF MEDICATION IS PART OF THE TREATMENT PLAN AND I WILL REQUEST THE PRODUCT INFORMATION INSERT AT THE TIME A PRESCRIPTION IS FILLED.   _____________________ _________ ___________________ PATIENT SIGNATURE DATE PHYSICIAN   _____________________ __________________________ PARENT/GUARDIAN (IF APPLICABLE) RELATIONSHSIP TO PATIENT ………………………………………………………………………………………………. update to plan: date initial of responsible party

Find a doctor you like and feel you can work with  Keep the doctor in the loop  Don’t overwhelm the doctor with data  Think carefully before rapid, large changes in dose or before changing more thing than one thing at a time.  Respectfully offer resources – don’t expect your doctor will read a book for you, but do expect your doctor is interested in other opinions from other doctors 



Look for Basic Competence: APBN Board Certified Child and Adolescent Psychiatrists were checked for competence in assessing autism, and for use of collateral information from family, school, and other professionals.



Look for Honesty: AACAP = a promise to be ethical and do their best



Helping parents determine when medication may be worth considering



Helping families navigate well to utilize their doctors and other providers

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Helping families orchestrate the whole set of interventions into a coherent and manageable plan



Good Luck!

 

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

Co-regulation  Engagement  Circles  Flow  Symbolic thinking  Logical social problem solving  Multi-causal thinking  Grey area thinking  Reflective thinking, stable sense of self, internal standard 

 Sensory

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

 Support

regulation and co-regulation by treating symptoms that get in the way, e.g., impulsivity, inattention, anxiety, rigid thinking, perseveration.  Widen tolerance of affective experience so the person is less likely to become overwhelmed.  Treat co-morbid conditions, e.g., depression.  Possibly: allow for or promote improved ability for abstract reasoning and thinking.

DIR®

is the main course Meds are the pickles…

A

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

and transferences & countertransferences (invisible and everpresent)

Peace,

from nearly anything that ails

you Rare Miraculous Awakenings

Seizures Weight

gain Insulin resistance Tardive Dyskinesia Neuroleptic Malignant Syndrome

 perseveration,

anxiety, depression may

improve  often the benefits are outweighed by overactivity, inattention, or even mania, rarely seizures, and sweating as a precursor to serotonin syndrome

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

 ‘The

plan that lived’, due to better focus and less overactivity

 Ragged

sleep, ratty moods, thin waifs with sunken eyes, stupors, tics, and occasional paranoia; cardiac and growth issues

 Reliable

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



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



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

 Find

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

case

synopsis video clips analysis discussion

K

Searcy - ?Meds for anxiety in autism, Jan 2008

 Failure

to make gains despite massive services

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

   

   



planned C/S at 39 wk., mild jaundice, WBC up but ok. constantly nursing, mom w/o sleep. crawled 9 mo, walked 11 mo words at 12 mo but slow to gain new ones and they didn’t stick well

13 mo: sudden stimming, classic ASD, but still cuddling FH: sister PDDNOS now ‘better’, cousin ASD; others: anxiety, OCD Sp Ed PK and CARES then ACES, Crimson, etc. medical: ?Sz, allergies to eggs, peanuts, amox, eczema

Medications: Trileptal, EEG improved; Spring 08 Citalopram at 10 mg helps anxiety; Fall 08 Metadate CD 15 mg.

Mar 08: ‘break the door’ MOV00732.MPG (0:10)  Sept 08: Malingo Toya ‘song and dance’ (0:55)  Mar 09: This Little Piggy (4:50)  May 09: Play with Dad (0:20)  May 09: Play wither Feder (1:09)  July 09: Play with sister (0:28) 

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



Axis I – Primary Diagnosis

Axis

II - Functional Emotional Developmental Capacities

    

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

Not there

Barely

Coregulate Engage

Islands

3/08

9/08

3/08

Circles

3/08

Flow

3/08

Symbolic

3/08

Logical

3/08,3/07,3/08

Multicaus al Grey area

3/08,3/07,3/08

Reflective

3/08,3/07,3/08

3/08,3/07,3/08

9/08, 3/09

3/09

9/08 9/08

9/08

Expand s

3/09 3/09

3/09

Comes back

Ok if not stress ed

Ok for age

03/08 – moments of gleam and a couple of circles when I get playfully in his way unplug the fan or stop him from crawling under my desk (before this he was seizing…)

09/08 - join and shift

the OC on AC to ram into couch;

shift OC on AC to blanket fan; fishing for feet – toya – making a song – somewhat symbolic

3/09

flow; malingo

– calmer and able to cuddle nearly the whole session with

mom, makes possible coaching mom for more elaboration of circles and some flow with her; can talk about toes, but not really more symbolic per se. (After this we add dad, sis, and dad ‘coaching’)

 

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

 Axis

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

AxisVI‐Child‐Caregiver and Family Patterns AxisVII‐Stress

Sensor y

Postural

Sensory seeking, distractible Auditory Visual Tactile Vestibular Proprioceptive Taste Odor

Best when core is supported 1 indicate desires ----3/08---2. mirror gestures 3. imitate gesture 4. Imitate with purpose. ----9/08---5. Obtain desires 6. interact: - exploration -purposeful ----3/09---- self help -interactions

Response to Communicatio n

Cues into important words 1.Orient ----3/08---2. key tones 3. key gestures 4. key words ----9/08---5. Switch auditory attention back and forth 6. Follow directions 7. Understand W ?’s ----3/09---8.abstract conversation.

Intent to Communica te

Visual Exploration

Spots fans at distance; fingers in eyes; rare gleam 2.focus on object 3.Mirror ----3/08---vocalizations 2. Alternate gaze ----3/08---3. Follow 2.. Mirror gestures another’s gaze to 3. gestures determine intent. 4. sounds 3. Switch visual 5.words attention ----9/08-------9/08---6. two –word 4. visual figure ground 7. Sentences 5. search for ----3/09---object 8. logical flow. ----3/09---6. search two areas of room 7. assess space, shape and materials. Often unintelligible

Praxis Perseverative ideas; can expand w/ support Ideation ----3/08---Planning (including sensory knowledge to do this) ----9/08---Sequencing ----3/09---Execution Adaptation

    

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

AxisVI‐Child‐Caregiver

Patterns AxisVII‐Stress

and Family



Learned to quiz him, and quizzing him



Can engage in some back and forth, coachable



Discomfort with him in public –so different from other kids – improving



Stress: eye issue harrowing, but improving as he becomes more connected.



MANY OF OUR FAMILIES HAVE A FORM OF PTSD!

Axis      

I – Primary Diagnosis

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

 

100. Interactive Disorders 200. Regulatory Sensory Processing Disorders

300.

Neurodevelopmental Disorders of Relating and Communicating

 

400. Language Disorders 500. Learning Challenges



300.1 Type I:

Early Symbolic, with Constrictions ; intermittent capacity for attending, relating, reciprocal social interaction, including social problem solving, and beginning use of meaningful ideas‐makes



300.2 Type II:

rapid progress

in a comprehensive program

Purposeful Problem Solving, with Constrictions; as above but only fleeting

social problem solving‐tend to make

steady, methodical progress



300.3 Type III: Intermittantly Engaged and Purposeful; only fleeting attention and engagement, occasional reciprocal social interaction with lots of support ‐ slow, steady progress possible, maybe with gradual use of words or phrases



300.4 Type IV: Aimless and Unpurposful; multiple regressions, maybe more neurologic challenges, very very slow progress



ICDL DIR DMIC AXIS I 300.3 NDRC level III:

slow progress when he has lots of support.



What works:

early on getting in the way, modifying perseveration, getting him on his back, fanning him, gradually more able to follow his lead, extending interactions.

What doesn’t work: didactics, adding ideas too quickly  Why: early on we used the drive of his perseveration to power 

interaction, now can often engage him over less intense things or using shared experiences (little piggies); position and physical support are still key to his ability to sustain interaction. 

Medications

have been very helpful to this child, allowing him to respond to developmentally supportive intervention.

 Mar

08:

we are in a dangerous and perseverative

 Sept

08:

crisis

– dysregulated

with meds and direction to the intervention, he

collaborative interaction  Mar 09: we are confident that with coaching his capacities will expand can be ‘entrained’ into

 Medication

management, and more…

 Guiding

the whole team, once and twice removed.

 As

the prescribing physician I have responsibility, accountability, and leverage - they come back

 Will

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