Prescribing For Young People With Learning DisabilityDr Don MacFarlane PhD., MB., MRCPsych, MSc., DPM

Lakeview, Gransha Park, Derry

Ethical 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

Dysmorphology in MLD and SLD

• Cortical agyria or cerebromalacia

• Agenesis or microcephaly

• Lateral ventricle malformations

• Anomalies of corpus callosum

• Subgenual cingulate gyrus

• Increased CSF

• Cerebellar and vermal hypogenesis

• Basal ganglia reduction

CNS Embryonic Development

MIDBRAIN STRUCTURES AND FUNCTIONS

PHYSICAL EXAMINATION IN SLD• Head circumference

• Height and weight

• Canthal distance

• Flat philtrum

• Intraorbital distance

• Breadth of forehead

• Facial muscle movement

• Clinodactly

• Abnormal nails

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

LD Care Pathways• Psychological

mental comorbidity and behaviour problems

offending

developmental pervasive disorders.

• Physical

sensory

profound, multiple or complex

nutrition,

epilepsy

BEXLEY Audit Findings

• 57% of clients regularly reviewed

• 29% had Challenging Behaviour Risk Assessment (FACE?)

• 51% had written care plan

• 22% had keyworker

• 32% had reasons recorded for no further assessment

• 55% had blood profiles regularly recorded

• 24% had diagnosis of autism; 68% had mental illness

Ethical Issues in MLD and SLD

• Seeking Consent

capability of taking decisionacting voluntarily without undue persuasiongiven enough information

• Good Practicepatient’s welfare is first concern

safety, dignity and comfort is maintained

treat with dignity and respect

listen to concerns and preferences

be open and honest

MEDICAL NEGLECT

• Child is at risk of harm if inaction

• Recommended care offers significant benefit

• Expected benefit is significantly greater than risk

• Access to care is available and not being used

• Caregiver understands the medical advice being given

FRASER GUIDELINES

• Child capable of giving consent

• Maturity and understanding

• Nature of consent required

• Can make reasonable assessment of the facts

• Knows advantages and disadvantages

• Consent can be considered true

MENTAL HEALTH ORDER SCENARIOS

• SCENARIO #1

MLD + Schizophrenia + Lymphoma + Injunction

• SCENARIO #2

MLD + Delusional + Forensic + Tribunal

• SCENARIO #3

HFA + Bed Closures + Medical School + Infringements

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

Clinical Depression

• Ego Threat – sadness, failure, loss of pleasure, blame, punishment, worthless

• Vegetation – sleep, fatigue, appetite, libido

• Arousal – energy, agitation, irritability, concentration, focus

ACTING OUT #1ADHD Bipolar Attache

dTrauma Personality ASD

Duration Constant Cyclical Reactive Reactive Constant Constant

Attention Short Distracted Stressed Avoidant Selective Sensory

Impulsivity

Careless Hedonistic Futile Triggered Reactive Thwarted

Esteem Tasked Grandiose Unloved Worthless Depleted Fragments

Mood Normal Elated Needy Sad Empty Brittle

Control Disrupts Hassles Sneaks Lacks Exhausts Exhausts

ACTING OUT #2ADHD Bipolar Attache

dTrauma Personali

tyASD

Opposition

Disrupts Defies Sneaks Projects Switches Resists

Blame Deflects Denies Projects Accepts Confirms Centred

Lying Deflects Uses Conjures Conceals Believes Weak

Temper Excited Frustrated Bottled Hidden Explodes Reactive

Entitled Fleeting Grandiose False Oppressed Coercive Reactive

Sensitivity

Blinkered Hot Misreads Frightened Smoulder Hot

ACTING #3ADHD Bipolar Attached Trauma Personali

tyASD

Awareness

Flooded Egoistic Self Split Self Myopic

Peers Transient Arguing Needy Detached Isolated Detached

Meds 1 MPD Risperdal Lustral Lustral Risperdal

Meds2 Strattera Zyprexa Prozac Prozac Comorbid

Meds 3 Clonidine Seroquel Circadin Comorbid

Meds 4 Buspirone Abilify Clonidine Comorbid

SPECIALIST PRESCRIBING

• Person-centred approach

• Evidence-based

• Care pathways (collaborative with mainstream)

• Maximise independence and social inclusion

• Minimise hospitalisation

• Promote safeguarding

• Fulfil legal and ethical requirements

ACTIONS OF DRUGS

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

CAVEATS with ADHD medication

• ADHD Assessment Instruments are not geared to MLD

• Rebound and ‘Poop Out’ are not reasons for discontinuation

• ADHD is easily mistaken for other conditions such as bipolar

• Developmental charts should be regularly consulted

• Bone profile and scanning should be considered

• Atomoxetine and SSRI combo is to be avoided

• Cardiac history and QTc should be monitored

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/Le

arningDisabilities-Finalv3.pdf ‘Merseyside Clinical Guidelines’

• http://www.rcpsych.ac.uk/pdf/FutureroleofpsychiatristsinLD%20services.pdf ‘Future Role of Psychiatrist in Learning Disability’ RCPsych

• http://depts.washington.edu/dbpeds/Dysmorphology%20Training%20Manual%201-10-08%20(2).pdf‘Dysmorphology Training Manual’.

• http://www.dhsspsni.gov.uk/consent-guidepart4.pdfSeeking Consent in MLD, DHSSPNI Document

• http://pediatrics.aappublications.org/content/120/6/1385.fullRecognising Medical Neglect

Thank You For Listening