Prescribing For Young People With Learning Disability

Food For ThoughtEthical Issues, Holistic Assessment and Clinical Practice

Food For Thought

‘We forfeit three-quarters of ourselves to be like other people’ Arthur Schopenaur

‘If a man does not keep pace with his companions, perhaps it is because he hears a different drummer. Let him step to the music that he hears, however measured or far away’ Henry David Thoreau

Developmental Disorder• Onset during gestation, from birth or from early childhood• Deviation from the average in how the child perceives, thinks

and feels• Encompasses domains of behaviour• Accompanied by distress and problems in performance

Pathophysiology in MLD

Emotional Instability• Conflicts with others• Inability to cope with being thwarted• Inability to consider consequences• ‘Meltdowns’• Confusion about differentness• Inability to visualise aims and preferences• Self-injurious behaviour

SWAP 200• At the mercy of spiralling emotions• No stable image of self• Anxiety about rejection and abandonment• Need for external soothing• Elicits mirrored feelings in others• Has disregard for safety or welfare of self and others• Unawareness of others’ needs

Clinical Depression• Ego Threat – sadness, failure, loss of pleasure, blame,

punishment, worthless• Vegetation – sleep, fatigue, appetite, libido• Arousal – energy, agitation, irritability, concentration, focus

Developmental Tasks• Capable v.Helpless• Adventurous v. Avoidant• Persistent v. Quitting• Affectionate v. Detached• Assertive v. Submissive• Volatile v. Calm

Behavioural Modelling• Self Fulfilment (Maslow)• Aspirations• Norms• Scripts• Empathy• Congruence• Goals

Behavioural Models• Reasoned Action (Ajzen)• Congruence (Frijda)• Dynamic Attachment (Crittenden)• Behavioural Analysis (Snyder)• Procedural Sequencing (Chaiken)• Reciprocity (Gambrill)• Mentalising (Fonagy)

Primary Emotions• Anger – demeaning offence against self• Anxiety – uncertain threat against self• Sadness – experience of irrevocable loss • Happiness – progress towards a goal• Pride – achievement of a goal• Love – affection for idealised other

Secondary Emotions• Relief• Frustration• Hostility• Disgust• Hurt• Embarassment

ACTING OUT #1ADHD Bipolar Attachment Trauma

Duration Constant Cyclical Reactive ReactiveAttention Short Distracted Stressed AvoidantImpulsivity Careless Hedonistic Futile TriggeredEsteem Tasked Grandiose Unloved WorthlessMood Normal Elated Needy Sad or AngryControl Disrupts Hassles Sneaks Lacks

ACTING OUT #2ADHD Bipolar Attachment Trauma

Opposition Disrupts Defies Sneaks ProjectsBlame Deflects Denies Projects AcceptsLying Deflects Uses Conjures ConcealsTemper Excited Frustrated Bottled Up HiddenEntitlement Fleeting Grandiose False OppressedSensitivity Blinkered Hot Misreads Frightened

ACTING OUT #3ADHD Bipolar Attachment Trauma

Awareness Flooded Egoistic Self SplitPeers Transient Arguing Needy DetachedMedication 1 Methylphenidate Risperidone Sertraline SertralineMedication 2 Atomoxetine Olanzapine Fluoxetine FluoxetineMedication 3 Clonidine Quetiapine MelatoninMedication 4 Buspirone Aripiprazole Clonidine

CAVEATS WITH SSRIs• SSRIs can cause A-V defects in first trimester of pregnancy• Impotence from SSRIs can be counteracted by Periactin• Contraceptives can be impaired by modafinil• Risperidone can induce hypomania• Fluoxetine can double blood levels of mood-stabilisers• Tryptophan can cause serotonin overload• ‘Poop-out’ on fluoxetine occurs in 20% of cases

CAVEATS with NEUROLEPTICS• Haloperidol loses its anxiolytic effect in higher doses• Abilify can improve executive functioning• Abilify can cause suicidality due to akathisia• High blood sugars with olanzapine if relative has diabetes• Risperidone does not work above 6mg daily in adults• High prolactin levels stunt growth and delay puberty

CAVEATS with ANTICONVULSANTS• Suicide risk can be increased with anticonvulsants• Fortnightly checks of LFTS and serum levels of Tegretol• Children and adolescents are resistant to mood-stabilising• Children with ADHD are prone to have behavioural side-

effects from mood-stabilisers• Atypical antipsychotics are just as effective

CASE STUDY (MLD+ASD+ADHD+BPD)• Aged 5 – ASD (aggression, agarophobic, insomnia, hyper) > risperidone 1mg nocte> global improvement ‘a new man’• Aged 6 – regressed > olanzapine 2.5mg nocte > mum says needs dose increased > 5mg nocte > excellent improvement• Aged 9 – regressed > risperidone 2.75mg• Aged 9 – ‘high and anxious’ > risperidone 1mg > labile, insomnia • Aged 13 - > ADHD > risperidone 1.5 mg > ‘excellent progress’

CASE STUDY continued

• Aged 13 – BST > mood improved, less agitated, on risperidone 1.5mg + >melatonin > ‘brilliant’ > ADHD?

• Aged 13 – YMRS, violent to Mum, BST continues >EEG > ADHD ‘confirmed’ > Medikinet > ‘good benefit’, ‘content’ relaxed’

• Aged 14 – Medikinet stopped due rebound effect > ‘back to normal’• Aged 14 – ‘giddy and lively’ > atomoxetine > EMW but ‘good effect’,

‘moods improved’, ‘happier and less tearful’• Aged 15 – giddy, echolalia, repetitive movement > BPD > valproate +

risperidone + atomoxetine• Aged 15 – atomoxetine discontinued > clonidine 0.75 mg

Useful Websites• http://amberlist.wordpress.com

‘Prescribing for Young People’• http://johnalstonmd.com/docs/ADD_Bipolar_RAD.pdf

‘Juvenile Bipolar Disorder’ (John Alston, Baltimore)• http://www.familyrelationsinstitute.org/include/dmm_model.htm

‘Dynamic Maturational Model’ (Patricia Crittenden, Miami)

Useful Websites #2• http

://www.merseycare.nhs.uk/Library/What_we_do/Clinical_Services/Pharmacy/LearningDisabilities-Finalv3.pdf ‘Merseyside Clinical Guidelines’

Thank You For Listening