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Things to consider in the use of medication for persons withdevelopmental and learning

disorders

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Assistant Clinical Professor, Dept of Psychiatry, University of California

at San Diego School of Medicine

Faculty, Interdisciplinary Councilon Developmental and LearningDisorders

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ICDL Faculty minimal - review of

clinical write ups, travel and roomfor summer institute

NIMH/ Duke University minimal

administrative time forpharmacogenetic research

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Quick history: Magda Campbell: haloperidolhelps social learning; others: methylphenidatecauses side effects without benefit.

Today: we try to treat target symptoms,carefully, based on responses in otherconditions to medications.

Takes time to assess, and re-assess.Marketing, and side effects, and efficacystudies.Efficiency study: CAPTN (Duke: John March, el al Im an et al).

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Most people consider meds becausethey feel stuck, maybe desperateEmergencies: aggression, depression,others?Lack of progress: in what areas?

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What do we want for he child?

What the meaning of the disability isto the family and to your child?Goal: a meaningful life socially,

emotionally, and cognitively.Requires a plan, and medicationalone is not a plan.

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regulatory issues/ motor and sensoryareas addressedengagement and reciprocitylanguage/ communicationcognition/ learningdaily living skills followed by broaderand broader areas of life skills, fromschool and playground to vocationalskills.

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Mirror neuron systems Joint attention and relationship-basedinterventionGxE: genetics and environmentPharmacogenetics

And then there is always the math

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

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Low Support - LowExpectation

(neglect)

Low Support - HighExpectation

(Just do it)

High Support - LowExpectation(walking on eggshells, moreand more constricted)

High Support - HighExpectation(respectful coaching)

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Is the program adequate?Will they change the childs brain andactually fix it?Will they injure the child?

What should I expect?

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Losing time while pulling the programtogetherDoing as much as possibleAwakenings should we go for a

miracle?

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We do not know enough to say you

really should medicateIf there is no emergency, you havemore time to think about it

When parents differ, if makes formore thoughtful planning

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Are you trying to save a placement or makeup 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 schoolRapid, large, or multiple changes are oftenproblematicGrid target symptoms vs. possible meds andfill in possible +s &-s

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Support regulation and co-regulation bytreating symptoms that get in the way,e.g., impulsivity, inattention, anxiety, rigid

thinking, perseveration.Widen tolerance of affective experience sothe person is less likely to becomeoverwhelmed.

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

Possibly: allow for or promote improvedability for abstract reasoning and thinking.

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Easy for the treatment team to react andoveruse medicationsSide effects often create significantdifficulties, e.g., behavioral activation

(SSRIs), increased perseveration(stimulants), sedation (someanticonvulsants, others).

Team treatment often becomes all aboutthe medication, ignoring engagement, otherfactors.Bottom line: medication most probably donot treat core symptoms, but might createmore affective availability, if you can avoidsignificant side effects.

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Find a doctor you like and feel you canwork with

Keep the doctor in the loop

Dont overwhelm the doctor with dataThink carefully before rapid, largechanges in dose or before changingmore thing than one thing at a time.

Respectfully offer resources dont expectyour doctor will read a book for you, but doexpect your doctor is interested in other

opinions from other doctors

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Helping parents determine whenmedication may be worth consideringHelping families navigate well toutilize their doctors and other

providersHelping families orchestrate thewhole set of interventions into acoherent and manageable planGood Luck!