psychotropic meds asilomar

8/14/2019 Psychotropic Meds Asilomar

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Asilomar 2009


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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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The Southern CaliforniaDIR/Floortime

Regional InstitutePasadena, Californiabegins October, 2009

Josh Feder, MD Diane Cullinane, [email protected]

[email protected]

Mona Delahooke, PhD Pat Marquart, MFT [email protected] [email protected]
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]


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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 consultation

and participation


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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 boyand a diagnostic system (20 min)

your stories(15 min)


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all slides will be posted on

circlestretch.blogspot.comStop me on the blue dots!


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Quick history: Magda Campbell: haloperidol helpssocial learning; others: methylphenidate causesside effects without benefit.

Today: we try to treat target symptoms, carefully,based on responses in other conditions tomedications.

Takes time to assess, and re-assess.

Big issues: marketing, side effects, and efficacy

studies. Efficiency study: CAPTN (Duke: John March, el al

Im an et al).


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Most people consider meds becausethey feel stuck, maybe desperateEmergencies: aggression, depression,

others?Lack of progress


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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.


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regulatory issues/ motor and sensory areasaddressed

engagement and reciprocity (vs. focus on

compliance) language/ communicationcognition/ learningdaily living skills followed by broader and

broader areas of life skills, from school andplayground to vocational skills.


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Are we asking too much of the child?

Of the family?Of the school?


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Low Support - Low Expectation

(neglect)

Low Support - High Expectation

(Just do it)

High Support - Low Expectation

(walking on eggshells, more andmore constrictede.g. gamers)

High Support - HighExpectation

(respectful coaching)


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Is the program adequate?Will they change the childs brain and

actually 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 reallyshould medicate

If there is no emergency, you have moretime to think about it

When parents differ, it can be anopportunity for more thoughtful planning


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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. alongwith complete history, physical, MSE, and collateralinformation.

Availability - doctor MUST stay in touch with family andschool

Rapid, large, or multiple changes are often problematic Grid target symptoms vs. possible meds and fill in possible

+s & -s


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Easy for the treatment team to react and overusemedications

Side effects often create significant difficulties,e.g., behavioral activation (SSRIs), increasedperseveration (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 sideeffects.


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elements of informed consent

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


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NAME: DOB: DATE:

DIAGNOSIS:TARGET SYMPTOMS:

TREATMENT PROTOCOL:ALTERNATIVE TREATMENTS DISCUSSED:POSSIBLE RESULTS OF NO TREATMENT:SIDE EFFECTS DISCUSSED:

FDA LABELING DISCUSSED:CONSENT AND ASSENT DISCUSSED:COMMENTS/QUESTIONS/CONCERNS:

I UNDERSTAND THIS CONSENT AND ALL HAS BEEN EXPLAINED TO ME. TREATMENT, INCLUDING USEOF MEDICATIONS IS VOLUNTARY AND I PLAN TO WORK WITH THE DOCTOR TO MAKE THE BEST USEOF THESE.

I CONSENT TO THE TREATMENT. IF MEDICATION IS PART OF THE TREATMENT PLAN AND I WILLREQUEST THE PRODUCT INFORMATION INSERT AT THE TIME A PRESCRIPTION IS FILLED.

_____________________ _________ ___________________ PATIENT SIGNATURE DATE PHYSICIAN

_____________________ __________________________ PARENT/GUARDIAN (IF APPLICABLE) RELATIONSHSIP TO PATIENT.

update to plan: date initial of responsible party


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Find a doctor you like and feel you can work with Keep the doctor in the loop Dont overwhelm the doctor with data

Think carefully before rapid, large changesin dose or before changing more thing thanone thing at a time.

Respectfully offer resources dont expect yourdoctor will read a book for you, but do expect your

doctor is interested in other opinions from otherdoctors


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Look for Basic Competence: APBN Board CertifiedChild and Adolescent Psychiatrists were checkedfor competence in assessing autism, and for useof collateral information from family, school, and

other professionals.

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


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Helping parents determine when medication maybe worth considering

Helping families navigate well to utilize their

doctors and other providers Helping families orchestrate the whole set of

interventions into a coherent and manageableplan

Good Luck!


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Can Medications Help Kids HaveBetter,

More Productive RelationshipsWith Us?


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Co-regulation Engagement Circles Flow

Symbolic thinking Logical social problem solvingMulti-causal thinking Grey area thinking Reflective thinking, stable sense of self, internal

standard


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Sensory processingPostural control/ motor planningReceptive communication

Expressive communicationVisual-spatial functionPraxis: ideation, planning, sequencing,

execution, adaptation


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DIR is the main courseMeds are the pickles


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A Good Enough WizardUnpredictable PotionsNefarious Forces:

syndromes & systems(affecting schools, social services, and industry)

andtransferences & countertransferences

(invisible and everpresent)


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Peace, from nearly anything that ailsyouRare Miraculous Awakenings


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SeizuresWeight gainInsulin resistanceTardive DyskinesiaNeuroleptic Malignant Syndrome


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perseveration, anxiety, depression mayimprove

often the benefits are outweighed by

overactivity, inattention, or even mania,rarely seizures, and sweating as aprecursor to serotonin syndrome


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For mood stabilization, oh, and fewer seizures Well Mrs Farkel Liver, pancreas, weight gain,

sedation, incontinence, drooling, and if you everwant to have babies beware of PCOS, loss of white

cells, bleeding problemssTegretols blood and cardiac problems Lamictals scathing rash, and unweildy interaction

with DepakoteTopamax: wt loss, but language loss; unreliability,

decreased sweating Others


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The plan that lived, due to better focusand less overactivity

Ragged sleep, ratty moods, thin waifs with

sunken eyes, stupors, tics, and occasionalparanoia; cardiac and growth issues


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Reliable anxiolytic, helpful for seizuresReliable loss of memory and motor control,

with inability to benefit from learning and

high risk of falling and automobileaccidents

Addiction is rampantALL MEMBERS OF THIS CLASS

(BENZODIAZEPINES) ARE PROBLEMATIC


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The number one cause of death byantidepressants due to overdose in the daysbefore SSRIs

CARDIOTOXIC: have people LOCK THEM UP!

and get serial EKGs w/ Cardiologist readings

Still, they are as effective or more effective thanany other antidepressants we have, and

clomipramine is more effective, generally thanSSRIs for OCD.


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Find a good enough Wizard, one whoknows the stories, good and bad, and who

listens to you and your people


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case synopsisvideo clipsanalysisdiscussion


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K Searcy - ?Meds for anxiety in autism, Jan2008

Failure to make gains despite massiveservices


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Autism SAFETY fingers in eyes extremely perseverative (fans) anxiety

over-activity tantrums language hard to take him out, (esp. dad)

?seizures.


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planned C/S at 39 wk., mild jaundice, WBC up but ok. constantly nursing, mom w/o sleep. crawled 9 mo, walked 11 mo words at 12 mo but slow to gain new ones and they didnt stick

well

13 mo: sudden stimming, classic ASD, but stillcuddling

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 helpsanxiety; Fall 08 Metadate CD 15 mg.


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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)


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Axis I Primary Diagnosis Axis II - Functional Emotional Developmental

Capacities Axis IIIRegulatorySensory Processing Capacities

AxisIVLanguage Capacities AxisVVisuospatial Capacities AxisVIChildCaregiver and Family Patterns AxisVIIStress


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Axis I Primary Diagnosis

Axis II - Functional EmotionalDevelopmental Capacities

Axis IIIRegulatorySensory Processing Capacities AxisIVLanguage Capacities AxisVVisuospatial Capacities AxisVIChildCaregiver and Family Patterns AxisVIIStress


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Notthere

Barely Islands Expands

Comesback

Ok ifnotstressed

Ok forage

Co-regulate

3/08 9/08 3/09

Engage 3/08 9/08 3/09

Circles3/08 9/08 3/09

Flow 3/08 9/08 3/09

Symbolic 3/08 9/08, 3/09

Logical 3/08,3/07,3/08

Multicausal

3/08,3/07,3/08

Grey area 3/08,3/07,3/08

Reflective 3/08,3/07,3/08


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03/08 moments ofgleamand a couple of circles when I getplayfully in his way unplug the fan or stop him fromcrawling 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 flow; malingotoya making a song somewhat symbolic

3/09 calmer and able to cuddle nearly the whole session with

mom, makes possible coaching mom for more elaborationof circles and some flow with her; can talk about toes, but notreally more symbolic per se. (After this we add dad, sis, anddad coaching)


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Axis I Primary Diagnosis Axis II - Functional Emotional Developmental Capacities

Axis IIIRegulatorySensory ProcessingCapacities

Axis IVLanguage CapacitiesAxis VVisuospatial Capacities AxisVIChildCaregiver and Family Patterns AxisVIIStress


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Sensory

Postural Response toCommunication

Intent toCommunicate

VisualExploration

Praxis -

Sensory

seeking,

distractible

Auditory

Visual

Tactile

Vestibular

Proprio-

ceptive

TasteOdor

Best when core is

supported

1 indicate desires

----3/08----

2. mirror gestures

3. imitate gesture

4. Imitate with

purpose.

----9/08----

5. Obtain desires6. interact:

- exploration

-purposeful

----3/09----

- self help

-interactions

Cues into important

words1.Orient

----3/08----2. key tones3. key gestures4. key words

----9/08----5. Switch auditoryattention back and

forth6. Follow directions7. Understand W ?s ----3/09----8.abstractconversation.

Often

unintelligible

3.Mirror

vocalizations

----3/08----

2.. Mirror gestures

3. gestures

4. sounds

5.words----9/08----

6. two word

7. Sentences

----3/09----

8. logical flow.

Spots fans at

distance; fingersin eyes; rare gleam2.focus on object

----3/08----2. Alternate gaze3. Followanothers gaze todetermine intent.3. Switch visual

attention----9/08----4. visual figureground5. search forobject----3/09----

6. search twoareas of room7. assess space,

shape andmaterials.

Perseverative

ideas; can expand

w/ support

Ideation

----3/08----

Planning

(including sensory

knowledge to do

this)

----9/08----Sequencing

----3/09----

Execution

Adaptation


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Axis I Primary Diagnosis Axis II - Functional Emotional Developmental Capacities Axis IIIRegulatorySensory Processing Capacities AxisIVLanguage Capacities AxisVVisuospatial Capacities

AxisVIChildCaregiver and FamilyPatternsAxisVIIStress


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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 from other kids improving

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

MANY OF OUR FAMILIES HAVE A FORM OF PTSD!


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Axis I Primary Diagnosis Axis II - Functional Emotional Developmental Capacities Axis IIIRegulatorySensory Processing Capacities AxisIVLanguage Capacities AxisVVisuospatial Capacities AxisVIChildCaregiver and Family Patterns AxisVIIStress


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300.1 Type I: Early Symbolic, with Constrictions ; intermittent capacity for attending,relating, reciprocal social interaction, including social problem solving, and beginning use of

meaningful ideasmakesrapid progress in a comprehensive program

300.2 Type II: Purposeful Problem Solving, with Constrictions; as above but only fleetingsocial problem solvingtend 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, steadyprogress possible, maybe with gradual use of words or phrases

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


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ICDL DIR DMIC AXIS I 300.3 NDRC level III:

slow progress

when he has lots of support.


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What works: early on getting in the way, modifyingperseveration, getting him on his back, fanning him, graduallymore able to follow his lead, extending interactions.

What doesnt 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 orusing shared experiences (little piggies); position and physicalsupport are still key to his ability to sustain interaction.

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


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Mar 08: we are in a dangerous crisis dysregulatedand perseverative

Sept 08: with meds and direction to the intervention, hecan be entrained into

collaborative interactionMar 09: we are confident that with coaching hiscapacities will expand


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Medication management, and more

Guiding the whole team, once and twiceremoved.

As the prescribing physician I haveresponsibility, accountability, and leverage- they come back


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Will you be careful with the meds?

Will you look at the whole picture?Will you continue to learn and explore?


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psychotropic meds asilomar

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