medication support for dir school programs

8/8/2019 Medication Support for DIR School Programs

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MEDICATION SUPPORT FORMEDICATION SUPPORT FORDIR SCHOOL PROGRAMSDIR SCHOOL PROGRAMS

Joshua D. Feder, MD, DFAPA

ICDL Fall Conference 2010McClean, Virginia


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Redacted for Posting

Case material removed Questions? email [email protected]


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Joshua D Feder MD

DFAPA Assistant Clinical Professor,

Dept of Psychiatry, University of Californiaat San Diego School of Medicine

Faculty, Interdisciplinary Council on

Developmental and Learning Disorders


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Disclosures

ICDL Faculty

NIMH/ Duke University

NIH R21 grant/ San Diego BRIDGE Collaborative


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Commercials

Because we build ideas together

And you can join us in the effort!


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circlestretch Help the child be Calm enough to interact Truly connected to others

In a continuous expanding balanced back and forth flow of

interaction Go for that gleam in the eye!!

http://www.circlestretch.com
http://www.circlestretch.blogspot.com/http://www.circlestretch.blogspot.com/


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The Southern California DIR/Floortime

Regional Institute

Pasadena, California October 2010- May 2011

Josh Feder, MD Diane Cullinane, MD

[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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!Support Parent Choice Today. .www dirfloortimecoc com


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!Support Parent Choice Today

. .www dirfloortimecoc com%And get 10 off with The Special!needs Project


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Thank You!

Families say a silent thank you

Greenspan & Wieder

Daniel Carlat

David Sackett (et. al.)

Ricki Robinson

Michael Chez

So many others


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Introduction

Assumptions: some familiarity withDIR/Floortime.

The program is paramount.

Reflective process is the key to a goodprogram.

Medication might help a good plan work


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DIR, because its

Broad whole child, supports family

Welcoming all about building love

Enriching closeness brings progress


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DIR quick guide

Developmental - regulation, warm trust,then a flow of enriching interactions

Individual sensory, motor,

communication, visual-spatial,cognitive

Relationship Based connecting andsupporting at many levels


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:Today s Outline

DIR in School Programs Reflective Process Considering medication

Case examples

Your experiences


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This handout will be posted onCirclestretch.com


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School Programs

IEP Goals: ideal vs. real its ok to workfrom where you are.

Our Metaphor: The Learning Tree

(+caregiver profile)


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The Learning Tree


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Practical DIR at School

Co-regulation, and avoiding meresensory breaks.

Understanding engagement

Flow of increasingly richer interactions Cuing a dyad, interpreting the situation,

and slowing things down


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A Flow of Interaction


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Find An Ally


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Reflective Process

There are always new challenges Nothing goes as expected

Staff rarely have the support theyneed and deserve to think about it

Make time a moment to listen.


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Reflective Process:in the moment

Humility: you do not have theanswer

Learn from staff to 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 inlater?

Set another time to check in.


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Medications

Rationale for using medication: lastresort vs. covering all bases

Controversies about medications in


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Controversies about medications indevelopmental and learning

disorders: Stimulants

Antidepressants

core symptoms

overmedication


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Evidence based medicine,

and informed consent


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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 Charlie Preschool 5/05 &


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Individual Differences Charlie Preschool 5/05 &Kindergarten 9/05

S e n s o r y o s t u r a l e sp o n se t oC o m m u n i c a t i o n nt e n t t oC o m m u n i c a tei s u a lE x p l o r a t i o n -r a x i s

Sensoryseeking,distractibleAuditoryVisualTactileVestibularProprio-

ceptiveTasteOdor

Low tone;A bit clumsy -impedes rapidreciprocity in themoment1 indicate desires2. mirror gestures3. imitate gesture

---- 05/05----4. Imitate withpurpose.5. Obtain desires6. interact:- exploration- purposefulself help-interactions

Trouble managingmore than one thingat a time1. Orient2. key tones

3. key gestures4. key words

---- 05/05----5. Switch auditoryattention back andforth6. Follow directions7. Understand

W ?s8.abstractconversation.

Dysarthric Logicaldiscourse isDifficult1. Mirrorvocalizations2.. Mirrorgestures

3. gestures4. sounds5.Words---- 05/05---6. two word

7. Sentences8. logical flow.

Distractible.focus on object

---- 05/05----2. Alternate gaze3. Follow anothersgaze to determineintent.3. Switch visual

attention4. visual figureground5. search for object6. search two areas ofroom7. assess space,shape and materials.

-

EasilyfrustratedIdeation-- 05/05---Planning(includingsensoryknowledge to

do this)

Sequencing

Execution

Adaptation


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Individual Differences Charley First Grade

S e n s o r y o s t u r a l e sp o n se t oC o m m u n i c a t i o n nt e n t t oC o m m u n i c a teV i s u a lE x p l o r a t i o n -r a x i s

Sensoryseeking,distractibleAuditoryVisualTactileVestibularProprio-ceptiveTasteOdor

Taste andodor arebetter

Low tone;A bit clumsy -impedes rapidreciprocity in themoment1 indicate desires2. mirror gestures3. imitate gesture4. Imitate withpurpose.

----3/07----5. Obtain desires6. interact:- exploration- purposefulself help-interactionsMuch betterpostural control not flopping onfloor

Trouble managingmore than one thingat a time1. Orient2. key tones

3. key gestures4. key words

----3/07----5. Switch auditoryattention back andforth6. Follow directions7. Understand

W ?s8.abstractconversation.Stronger foundation

Dysarthric Logicaldiscourse isDifficult1. Mirrorvocalizations2.. Mirrorgestures3. gestures4. sounds5.words

----3/07----6. two word7. Sentences8. logical flow.

NOTCHANGED

Distractible.focus on object----3/07----2. Alternate gaze3. Follow anothersgaze to determineintent.3. Switch visualattention4. visual figureground5. search for object6. search two areas ofroom7. assess space,shape and materials.Can focus pretty wellon an object now

EasilyfrustratedIdeation

Planning(includingsensoryknowledge todo this)----3/07----Sequencing

Execution

Adaptation

A stepforward..


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Sample Full FEDL (Charlie)

otthere Barely Islands Expands omesback k ifotstressedk forage-oregulate 3/06 3/07 3/08 3/09Engage 3/06 3/07 3/08 3/09

Circles 3/06, 3/07 3/08 3/09Flow 3/06 3/07 3/08, 3/09Symbolic 3/06 3/07, 3/08 3/09Logical 3/06 3/07, 3/08 3/09Multicausal 3/06, 3/07 3/08 3/09rey area 3/06, 3/07, 3/08, 3/09Reflective 3/06, 3/07 3/08, 3/09

Relationships Caregiver Profiles:


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Relationships - Caregiver Profiles:

Not yet able tosupport

Just starting tosupport

Islands ofsupport

Moderatelyeffective insupporting

50%

Becomingconsistent inability to

support

Effectiveexcept whenstressed

Very Effectivein supporting

Comforting the

childFindingappropriatelevel ofstimulationPleasurablyengages thechildReads childsemotionalsignalsResponds tochilds

emotionalsignalsTends toencourage thechild

]

e a ons ps - areg ver ro es: rs gra e


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e a ons ps areg ver ro es: gteacher,aide



Islands ofsupport


50%


support



Comforting the

child

Not fuzzy, but

not reactive

mellow

Findingappropriatelevel ofstimulation

directive unflappable

Pleasurablyengages thechild

directive Persistent attemptsto engage him

Reads childsemotionalsignals

Sees when he isupset

Can predictwhen he willbecome upset

Responds tochilds

emotionalsignals

Unsure what to do Interested in the flowof activity, not

interactionTends toencourage thechild

directive Wants himregulated so hecan learn (notinteract per se)

e a ons ps - areg ver ro es: secon gra e


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e a ons ps areg ver ro es: gteacher, resource teacher, aide



Islands ofsupport


50%


support



Comforting the

child

Kind and clear

mellow

Really there for

him, can helphim settleFindingappropriatelevel ofstimulation

directive Pretty good withhim

Calm andpositive, able toflexibly shiftlevel ofstimulation

Pleasurablyengages thechild

directive Learning to engage Some nice non-verbal flow

Reads childsemotionalsignals

Predict when heis upset

Tries hard to dothis in the moment

Naturally readshis cues

Responds tochilds

emotionalsignals

Still unsure what to do Interested in theflow of interaction

Naturallyresponds

Tends toencourage thechild

Still directive Strong desire tosee himregulated andengaged

Regulated forinteraction;coaches aides,staff


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Lots of Details to RushThrough

Get the details of the rationale fromcirclestretch.com

Ill slow down when we talk about the

specific meds Well work through the new stuff

together never really formally donebefore today ever.

(and on no sleep so it should beinteresting)


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Medications Approved bythe FDA for Marketing forthe Treatment of Autism

Risperdal - 10/06 - IrritabilityAbilify - 11/09 Irritability

Th k d H G d


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Thanks and Have a GoodDay!


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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 Harm non-maleficence


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4 Main Principles of MedicalEthics*

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.

Hi t f T i t d


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History of Trying to doGood

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 marketing forspecific symptoms of specificconditions

Allows doctors to use medications forwhatever they think is appropriate

FDA A l


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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 DoStudies On Medications in Kidswith ASDs

Kids are hard to find

Kids have multiple diagnoses

Kids with Autism are a very mixed group

New approaches:


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New approaches:

CAPTNChild & AdolescentPsychiatry Trials Network

NIH / Duke

Efficiency Studies

Pharmacogenetics

Results pending

The upshot for the


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The upshot, for themoment

Approval is for BIG MARKETS

Most psychiatric medication for kids isexperimental


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Doctors Need:

To know a lot

Respect for troubleSteady care

Judgment & Experience

Clinical Judgment & Experience


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Clinical Judgment & Experience

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. hepaticfailure, 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

Elements of Informed Consent


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Elements of Informed Consent

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 PROCESS


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So why use meds?

Can help, sometimesdramatically

Duty to Inform

Good information is part of


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Good information is part ofgood medical care

Could help, and perhapsavoid harm

Standard of care

Practice guidelines

Evidence Based Medicine

Evidenced Based


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Evidenced BasedMedicine Sackett, et. al. British Medical Journal

1996;312:71-72 (13 January)

the conscientious, explicit, and

judicious use of current best evidencein making decisions about the care ofindividual patients.


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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

Misuse of Evidence Based


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Misuse of Evidence BasedMedicine

Cost cutters

Vested Interests

Convinced Clinicians


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Gold Standard Evidence

Double BlindPlacebo (or wait list) Controlled

Prospective

Randomized

Multiple Subjects


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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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And People are Human

Narrow thinking

Emotional reasoning

Placebo effects

References: How Doctors Think Groopman; Science and Fiction in

Autism Schreibman; Lies, DamnLies, and Science Seethaler


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So EBM requires:

Currentbest evidence

Clinical expertise & judgment


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Evidence Changes Over

Time

Half changes every 5 years

50% is wrong

We dont which half


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Working with doctors

Find one you can work with

Keep the doctor in the loopDont overwhelm with dataDoctors can be confused

(biomedical)Respectfully offer resourcesGood doctor consult other doctors


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Finding a doctor

Competence: APBN BoardCertified

Ethics: AACAP= try their best


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The Role of Medication

Overview

Progress?

A Good Enough ProgramA General Approach to

Medication

Gridding the Problem

A Q i k Hi t f


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A Quick History of

Medications in Autism: 1989 Magda Campbell: haloperidol helps social

learning; others: methylphenidate causes sideeffects without benefit.

1990s - 2006: treating target symptoms, based onresponses in other conditions to medications; lotsof use of neuroleptics for aggression, 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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Being stuck

Most people consider meds becausethey feel stuck, maybe desperate

Emergencies: aggression, depression,others?

Lack of progress

What kind of progress is


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What kind of progress is

important?

What do we want for our children?

The usual wish: a meaningful life

(socially, emotionally, maybe cognitively)

Requires a plan, and medication alone is nota plan.


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A Good Plan Is Complex:

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

Sometimes the plan is not


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Sometimes the plan is notworking:

Are we asking too much of a child?

Of a family? Of a school?

Th C l Q i


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The Central Question

Are you trying to improve an appropriatesituation or make up for a bad one?


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Other Issues?

Will they change my childs brain and fix it?

Could they injure my child? What should I expect?

Other Common Reasons


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Other Common Reasonsto Consider Medications

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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Reasons to Hold Off

Cant guarantee results

If no emergency, theres time When parents differ Side effects Treatment teams all about the meds

A G l A h


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A General Approach:

Complete workup a must: consider (24 hour) EEG, labs, etc.along with complete history, physical, time with the child and family, 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 newdimensional axes 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 touch with family and school

GOLDEN RULE: think carefully before rapid,large changes in dose or before changingmore thing than one thing at a time.

Gridding Target


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Gridding TargetSymptoms

Target symptoms Prioritizing Symptoms

Core Symptoms

N Y S t


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Name Your Symptoms

Activity, impulsivity Anger Attention Anxiety, specific fears

Cognition Depression GI Distress Moodinstability, irritability, aggression Motor

Planning O/C, rigidityPerseverative Pain Reciprocalinteraction

Seizures


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C S t ?


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Core Symptoms?

RelatingCommunicatingHealthy development: connected, regulated

emotions that breathe life into adaptive thinking

and planning

Medication may help core


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y psymptoms,

but mostly indirectly 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.

Th B tt Li


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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.

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 careprovider for further information

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, unstablemood, tics, obsessiveness, etc.

Drug diversion vs. drug abuse risk ADHD and ASD Often makes a good plan workable.

SSRIs


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SSRIs

One of many classes of antidepressants Can really help depressed mood, maybe anxiety,

less likely obsessiveness (although works wellfor that for neurotypicals)

Prozac (fluoxteine), Zoloft (sertraline), Paxil

(paroxetine), Luvox (fluvoxamine), Celexa &Lexapro (citalopram). Similar possible side effects: behavioral

activation, weight gain (and loss), moodinstability, lower seizure threshold, etc.

Black box warning about suicidal thinking vs.lower rates of actual suicide in people treatedwith SSRIs

Neuroleptics


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Neuroleptics

Zyprexa (olanzapine), Risperdal (risperidone), Abilify(aripiprizole), Seroquel (quetiapine), Geodan(ziprasidone), Haldol (haloperidol), Mellaril(thioridizine), Thorazine (chlorpromazine) andothers.

Discovered while looking for cold pills, developed forsymptoms of psychosis.

Helping aggression, mood stability, and miracles? Aswell as tics, and adjunct for depression,perseveration, etc.?

Side effects can include weight, lipid, and sugarissues, as well as seizures, fevers (NMS) and newabnormal movements (TD), stroke (elderly), cardiac

Should we always consider neuroleptics?

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

Might help other medications work better

(stimulants, antidepressants) Combined pharmacology vs. polypharmacy

Sudden sopping might make seizures more likely

Specific AEDs


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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 whenusing with Lamictal

Tegretol (carbemazepine) - ?reliable, watch levels,blood counts, EKG, lots of drug interactions,weight gain, sedation, rash

Trileptal (oxycarbezine) Tegretol light?; motor

problems, electrolyte issues, rash?

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 weightloss, loss of expressive language, usually need togo slow.

Neurontin (gabapentin) Does it work at all? Does itharm at all? Does help pain syndromes.

Lyrica (pregabalin) for pain in fibromyalgia, partial

seizures Zarontin (ethosuccimide) for partial/ absence

seizures; liver issues

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, moodinstability including depression and hypomania

Pulsed dosing regimens

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

Other Commonly


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yConsidered Medications

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

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 crossreactions

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-asparticacid (NMDA) glutamate receptor, this

drug was hypothesized to potentiallymodulate learning, blockexcessiveglutamate effects that can includeneuroinflammatoryactivity, and influenceneuroglial activity in autism

Meds that I often avoid


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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 andhypertensive crisis must be considered; lots ofdrug-drug interactions

Special Caution on


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pBenzodiazepines!

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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Getting back to the


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tree


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GRIDDING OUT TARGET SYMPTOMS VS. POSSIBLE TREATMENTS

FOR DEVELOPMENTAL AND LEARNING DISORDERS (INCLUDING ASDs)Targets SensorProcessing

otoronend otorPlanning

ReceptivCommunicationxpressiveCommunication

isualSpatial raxis thermedical Etc Comments

Stimulants WtHtticsSSRIs ,t HtSzNeuroleptics .t SzTDNM SAEDs .ultESteroids ult SE

entral AlphaAgonists SleepBPtcIST OTHER!REATMENTS


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FOR DEVELOPMENTAL AND LEARNING DISORDERS (INCLUDING ASDs)Targets -oregulation

Engagement Circles Flow Symbolic Logical Multicausal Nuance Reflective Numbe10 ? tc Comments

Stimulants WtHtticsSSRIs ,t HtSzNeuroleptics .t SzTDNMSAEDs .ultESteroids ult SE



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FOR DEVELOPMENTAL AND LEARNING DISORDERS (INCLUDING ASDs)Targets Reading. . Writing Arithmet.c thicalules radeskills

Swimming. tc Comments

Stimulants WtHtticsSSRIs ,t HtSzNeuroleptics .t SzTDNMSAEDs .ul tESteroids ult SE



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FOR DEVELOPMENTAL AND LEARNING DISORDERS (INCLUDING ASDs)Targets Comfortinghechild

inding an ppropriateevel ofstimulation

Pleasurbleengaginth echild

eadinghe hi ld s motionalsignals

espondingo thehild s motionalsignals

Encourain ghe hi ld sdevelopment

Etc Comments

Stimulants WtHtticsSSRIs ,t HtSzNeuroleptics .t SzTDNMSAEDs .ul tESteroids ult SE



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Case Examples

Abnormal Involuntary Movement Scale (AIMS)


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Summary:


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Summary:

Look at the whole picture

Be careful with meds Engage the Child

Your Experiences?

medication support for dir school programs

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