psychiatry treatment in individuals with developmental delays philip l. baese, md assistant clinical...

Psychiatry Treatment in Psychiatry Treatment in Individuals with Individuals with

Developmental DelaysDevelopmental DelaysPhilip L. Baese, MDPhilip L. Baese, MD

Assistant Clinical Professor of PsychiatryAssistant Clinical Professor of PsychiatryUniversity of Utah, Department of PsychiatryUniversity of Utah, Department of Psychiatry

Neurobehavior/HOME ProgramNeurobehavior/HOME Program

Background IssuesBackground Issues

Under-recognized/under-treated psychiatric problemsUnder-recognized/under-treated psychiatric problems Why?Why?

Doesn’t fit neatly into descriptive categories of DSM IVDoesn’t fit neatly into descriptive categories of DSM IV Behaviors themselves become the focus of treatment, without Behaviors themselves become the focus of treatment, without

understanding underlying etiologyunderstanding underlying etiology Complicating medical problemsComplicating medical problems Complex psychosocial environments with variable Complex psychosocial environments with variable

amounts/consistency of collateral information from observersamounts/consistency of collateral information from observers

Increased risk of psychiatric illness in those with MR Increased risk of psychiatric illness in those with MR around 2-3X that of general populationaround 2-3X that of general population

Prevalence estimates of 30-70% of those with MR have Prevalence estimates of 30-70% of those with MR have an additional psychiatric diagnosisan additional psychiatric diagnosis

Typical Diagnostic CategoriesTypical Diagnostic Categories

Mood DisordersMood Disorders DepressionDepression Bipolar DisorderBipolar Disorder

Anxiety DisordersAnxiety Disorders Generalized AnxietyGeneralized Anxiety Panic DisorderPanic Disorder Post-traumatic Stress DisorderPost-traumatic Stress Disorder Obsessive Compulsive DisorderObsessive Compulsive Disorder

Autism Spectrum Disorders (ASD)/Pervasive Autism Spectrum Disorders (ASD)/Pervasive Developmental Disorders (PDD)Developmental Disorders (PDD) Asperger’sAsperger’s AutismAutism

Typical Diagnostic CategoriesTypical Diagnostic Categories

Disruptive Behavior DisordersDisruptive Behavior Disorders Oppositional Defiant DisorderOppositional Defiant Disorder Conduct DisorderConduct Disorder Attention Deficit/Hyperactivity DisorderAttention Deficit/Hyperactivity Disorder

Tic/Stereotypic Movement DisordersTic/Stereotypic Movement Disorders Tourette’s SyndromeTourette’s Syndrome

Psychotic DisordersPsychotic Disorders SchizophreniaSchizophrenia

General Aspects of Mental General Aspects of Mental RetardationRetardation

Significantly subaverage intellectual Significantly subaverage intellectual functioning (intelligence quotient below the functioning (intelligence quotient below the 70-75 range measured on standardized 70-75 range measured on standardized test)test)

Significantly impaired adaptive functioningSignificantly impaired adaptive functioning Onset prior to age 18Onset prior to age 18 85% fall in the mild-moderate range85% fall in the mild-moderate range

General Aspects of Mental General Aspects of Mental RetardationRetardation

35% an identifiable genetic cause is found 35% an identifiable genetic cause is found (such as Fragile X Syndrome, Down’s (such as Fragile X Syndrome, Down’s Syndrome, etc.)Syndrome, etc.)

<10% a malformation syndrome of <10% a malformation syndrome of unknown origin is foundunknown origin is found

33% external/pre/peri/post natal factors 33% external/pre/peri/post natal factors can be identified (infections, trauma, can be identified (infections, trauma, toxins, hypoxia, drug exposure, toxins, hypoxia, drug exposure, prematurity)prematurity)

Challenging Behaviors: The Big Challenging Behaviors: The Big FourFour

1.1. Self-injurious BehaviorSelf-injurious Behavior

2.2. Physical Aggression towards othersPhysical Aggression towards others

3.3. Destruction of PropertyDestruction of Property

4.4. Inappropriate Sexual BehaviorsInappropriate Sexual Behaviors

Broad Etiologic CategoriesBroad Etiologic Categories

1.1. Medical ConditionsMedical Conditions Genetic disorders with identifiable “behavior” Genetic disorders with identifiable “behavior”

phenotypesphenotypes Prader-Willi SyndromePrader-Willi Syndrome Down’s SyndromeDown’s Syndrome William’s SyndromeWilliam’s Syndrome FG SyndromeFG Syndrome Fragile X SyndromeFragile X Syndrome Smith-Magenis SyndromeSmith-Magenis Syndrome


1.1. Medical ConditionsMedical Conditions EpilepsyEpilepsy

Partial complexPartial complex GeneralizedGeneralized absenceabsence

Endocrinologic/Metabolic DisordersEndocrinologic/Metabolic Disorders Thyroid diseaseThyroid disease DiabetesDiabetes Wilson’s Disease (copper metabolism)Wilson’s Disease (copper metabolism)

Toxin EffectsToxin Effects Lead poisoningLead poisoning Fetal alcohol (or other drug) effectsFetal alcohol (or other drug) effects

Sleep DisordersSleep Disorders Obstructive sleep apnea (central and peripheral)Obstructive sleep apnea (central and peripheral) Periodic limb movement disorderPeriodic limb movement disorder narcolepsynarcolepsy


1.1. Medical ConditionsMedical Conditions Gastrointestinal ConditionsGastrointestinal Conditions

ConstipationConstipation RefluxReflux

Infections/PainInfections/Pain Chronic otitis, dental abscess, sinusitisChronic otitis, dental abscess, sinusitis

Toxin EffectsToxin Effects Lead poisoningLead poisoning Fetal alcohol (or other drug) effectsFetal alcohol (or other drug) effects

Sleep DisordersSleep Disorders Obstructive sleep apnea (central and peripheral)Obstructive sleep apnea (central and peripheral) Periodic limb movement disorderPeriodic limb movement disorder NarcolepsyNarcolepsy


2.2. Psychiatric DisordersPsychiatric Disorders

3.3. Adaptive Dysfunction (mismatch between Adaptive Dysfunction (mismatch between individual and environment)individual and environment)

COMMUNICATION limitationsCOMMUNICATION limitations Parental temperamentParental temperament Level of supervision/supportLevel of supervision/support Failure to recognize/manage major life changes Failure to recognize/manage major life changes

(puberty, graduation from school system, move out (puberty, graduation from school system, move out of family of origin’s home, loss)of family of origin’s home, loss)

Treatment ApproachTreatment Approach

Assess each of the broad categories listed Assess each of the broad categories listed above and exclude medical causes firstabove and exclude medical causes first

Functional Analysis of BehaviorFunctional Analysis of Behavior Biopsychosocial formulationBiopsychosocial formulation

Family history is importantFamily history is important Early developmental history is importantEarly developmental history is important Psychosocial history is important (assess Psychosocial history is important (assess

home life, school life, and peer relationships)home life, school life, and peer relationships)

Treatment ApproachTreatment Approach

Formulate a working hypothesisFormulate a working hypothesis Consider medication side-effects or adverse-Consider medication side-effects or adverse-

effects as a primary causeeffects as a primary cause Consider a worsening or undetected medical Consider a worsening or undetected medical

cause (e.g., worsening seizure control or cause (e.g., worsening seizure control or sleep apnea)sleep apnea)

If underlying psychiatric illness suspected, If underlying psychiatric illness suspected, consider psychopharmacologic trialconsider psychopharmacologic trial

General Rules for General Rules for Psychopharmacology in DD Psychopharmacology in DD

PopulationPopulation1.1. All bets are offAll bets are off – dealing with ‘fragile’ brains – dealing with ‘fragile’ brains

that do not always respond as expectedthat do not always respond as expected2.2. Start low/go slowStart low/go slow – begin at low dosages – begin at low dosages

(1/3-1/2 of usual dose in non-DD population(1/3-1/2 of usual dose in non-DD population3.3. Be methodicalBe methodical – make one change at a time – make one change at a time

and wait adequate amount of time for a and wait adequate amount of time for a response; quantify response as much as response; quantify response as much as possible (e.g., serial rating scales)possible (e.g., serial rating scales)

4.4. Follow-up frequently Follow-up frequently – reassess on a – reassess on a frequent/ongoing basis for adverse effectsfrequent/ongoing basis for adverse effects

General Rules for General Rules for Psychopharmacology in the DD Psychopharmacology in the DD

PopulationPopulation Additional ConsiderationsAdditional Considerations

Compliance with oral medicationsCompliance with oral medications transdermal patchtransdermal patch Intramuscular injectionIntramuscular injection Liquid/rapidly dissolving preparationsLiquid/rapidly dissolving preparations

Need for invasive monitoring for side effectsNeed for invasive monitoring for side effects Drug levelsDrug levels Liver and bone marrow functionLiver and bone marrow function EKG (QTc interval)EKG (QTc interval)

Interactions with other medications, including over-the-counter, Interactions with other medications, including over-the-counter, herbals, etc.herbals, etc.

Effects of multiple time/day dosing on providers/school systemEffects of multiple time/day dosing on providers/school system Risk of ingestion or overdoseRisk of ingestion or overdose

Commonly Used MedicationsCommonly Used Medications

Depression/AnxietyDepression/Anxiety SSRI = SSRI = sselective elective sserotonin erotonin rreuptake euptake

iinhibitornhibitor Fluoxetine = Prozac (20 – 60 mg)Fluoxetine = Prozac (20 – 60 mg) Sertraline = Zoloft (50 – 200 mg)Sertraline = Zoloft (50 – 200 mg) Paroxetine = Paxil (20 – 60 mg)Paroxetine = Paxil (20 – 60 mg) Fluvoxamine = Luvox (50 -200 mg)Fluvoxamine = Luvox (50 -200 mg) Citalopram = Celexa (20 – 60 mg)Citalopram = Celexa (20 – 60 mg) Escitalopram = Lexapro (5 – 20 mg)Escitalopram = Lexapro (5 – 20 mg)


Depression/AnxietyDepression/Anxiety BenzodiazepinesBenzodiazepines

Clonazepam = Klonopin (0.25 – 6 mg)Clonazepam = Klonopin (0.25 – 6 mg) Diazepam = Valium (5 – 20 mg)Diazepam = Valium (5 – 20 mg) Lorazepam = Ativan (0.5 – 8 mg)Lorazepam = Ativan (0.5 – 8 mg)

OtherOther Buspirone = Buspar (5 – 30 mg)Buspirone = Buspar (5 – 30 mg)

MMA = mixed mechanism antidepressantsMMA = mixed mechanism antidepressants Venlafaxine = Effexor (50 – 300 mg)Venlafaxine = Effexor (50 – 300 mg) Bupropion = Wellbutrin (75 – 300 mg)*Bupropion = Wellbutrin (75 – 300 mg)* Duloxetine = Cymbalta (20 – 60 mg)Duloxetine = Cymbalta (20 – 60 mg)

*lowers seizure threshold/contraindicated with epilepsy*lowers seizure threshold/contraindicated with epilepsy

Expected Response/Adverse Expected Response/Adverse EffectsEffects

SSRIs: takes 3-6 weeks or more for anxiety for SSRIs: takes 3-6 weeks or more for anxiety for potential benefitpotential benefit

MMAs: takes 2-4 weeks for potential benefitMMAs: takes 2-4 weeks for potential benefit Adverse Effects/Side Effects that are common Adverse Effects/Side Effects that are common

include diarrhea, GI upset, sexual dysfunction, include diarrhea, GI upset, sexual dysfunction, sleep problems, sedation, paradoxic agitation or sleep problems, sedation, paradoxic agitation or “activation” of manic symptoms“activation” of manic symptoms

Benzodiazepines: work within 1-2 hoursBenzodiazepines: work within 1-2 hours Adverse Effects/Side Effects include Adverse Effects/Side Effects include

disinhibition, agitation, sedationdisinhibition, agitation, sedation


Mood Dysregulation (Bipolar): so-called “mood Mood Dysregulation (Bipolar): so-called “mood stabilizers”stabilizers” Non-AEDsNon-AEDs

Lithium = Eskalith (150 – 1200 mg) [blood level 0.8-1.2)Lithium = Eskalith (150 – 1200 mg) [blood level 0.8-1.2)

AEDs (antiepileptic drugs)AEDs (antiepileptic drugs) Divalproate = Depakote (125 – 1500 mg) [blood level 80-Divalproate = Depakote (125 – 1500 mg) [blood level 80-

100]100] Carbamazepine = Tegretol (200 – 800 mg) [blood level 8-10]Carbamazepine = Tegretol (200 – 800 mg) [blood level 8-10] Oxcarbazepine = Trileptal (300 – 1200 mg)Oxcarbazepine = Trileptal (300 – 1200 mg) Lamotragine = Lamictal (50 – 400 mg)Lamotragine = Lamictal (50 – 400 mg) Gabapentin = Neurontin (300 – 2000 mg)Gabapentin = Neurontin (300 – 2000 mg)


Lithium: can work within 7-10 days or Lithium: can work within 7-10 days or sooner; therapeutic blood level is keysooner; therapeutic blood level is key

Adverse Effects include upset stomach, Adverse Effects include upset stomach, diarrhea, excessive urination, cognitive diarrhea, excessive urination, cognitive dulling, weight gain, acne, tremordulling, weight gain, acne, tremor

Toxic Effects (overdose) are life Toxic Effects (overdose) are life threatening: gait problems, confusion, and threatening: gait problems, confusion, and comacoma

Therapeutic blood level is keyTherapeutic blood level is key


AEDs: can work within days for stabilizing mood symptomsAEDs: can work within days for stabilizing mood symptoms Often need to be tapered up and down slowly (shouldn’t be stopped Often need to be tapered up and down slowly (shouldn’t be stopped

abruptly due to risk of rebound siezure)abruptly due to risk of rebound siezure) Some require therapeutic blood level for optimal efficacySome require therapeutic blood level for optimal efficacy Some require monitoring of liver function and bone marrow function Some require monitoring of liver function and bone marrow function

(carbamezepine/divalproate)(carbamezepine/divalproate) Common side effects include weight gain, cognitive dulling, Common side effects include weight gain, cognitive dulling,

sedation, tremorsedation, tremor Blood monitoring can be difficult in DDMR populationBlood monitoring can be difficult in DDMR population Some more effective than others (divalproate > carbamezepine > Some more effective than others (divalproate > carbamezepine >

gabapentin)gabapentin) Lamotragine is promising (antidepressant effects), but must be Lamotragine is promising (antidepressant effects), but must be

tapered upward slowly due to risk of life threatening rash (Steven tapered upward slowly due to risk of life threatening rash (Steven Johnson Syndrome)Johnson Syndrome)


Agitation/Mood Dysregulation/OverarousalAgitation/Mood Dysregulation/Overarousal ““Atypical” Antipsychotics (block dopamine Atypical” Antipsychotics (block dopamine

receptors and serotonin receptors)receptors and serotonin receptors) Risperidone = Risperdal (0.5 – 8 mg)Risperidone = Risperdal (0.5 – 8 mg) Olanzapine = Zyprexa (5 – 30 mg)Olanzapine = Zyprexa (5 – 30 mg) Quetiapine = Seroquel (50 – 800 mg)Quetiapine = Seroquel (50 – 800 mg) Ziprasidone = Geodon (40 – 120 mg)Ziprasidone = Geodon (40 – 120 mg) Arapiprazole = Abilify (5 – 20 mg)Arapiprazole = Abilify (5 – 20 mg)


Atypical AntipsychoticsAtypical Antipsychotics Work within hours (calming/sedating effects) to days (mood stabilizing Work within hours (calming/sedating effects) to days (mood stabilizing

effects)effects) Common side effects include weight gain (except Common side effects include weight gain (except

ziprasidone/aripiprazole), long-term metabolic changes and insulin ziprasidone/aripiprazole), long-term metabolic changes and insulin resistance (can lead to diabetes), sedationresistance (can lead to diabetes), sedation

Changes in cardiac rhythm can occur (potentially lethal, such as Changes in cardiac rhythm can occur (potentially lethal, such as prolonged QTc interval)prolonged QTc interval)

Less risk of EPS (extrapyramidal symptoms), but can occur = drug Less risk of EPS (extrapyramidal symptoms), but can occur = drug induced Parkinsonism (cogwheel rigidity, tremor, wide based gait, induced Parkinsonism (cogwheel rigidity, tremor, wide based gait, drooling); dyskinesiasdrooling); dyskinesias

Serious long-term effects include tardive dyskinesia = involuntary Serious long-term effects include tardive dyskinesia = involuntary movements that are not reversible, even with drug discontinuationmovements that are not reversible, even with drug discontinuation

Life threatening reaction = NMS (neuroleptic malignant syndrome) Life threatening reaction = NMS (neuroleptic malignant syndrome) characterized by stiffness, vital sign instability, fever, deleriumcharacterized by stiffness, vital sign instability, fever, delerium


Disruptive Behavior Disorders (like AD/HD)Disruptive Behavior Disorders (like AD/HD) Stimulants*Stimulants*

Methylphenidate = Ritalin (multiple long-acting formulations)Methylphenidate = Ritalin (multiple long-acting formulations) Dextroamphetamine = DexedrineDextroamphetamine = Dexedrine Mixed amphetamine salts = AdderallMixed amphetamine salts = Adderall

*dosed by weight: methylphenidate least potent with average *dosed by weight: methylphenidate least potent with average dose of 1 mg/kg/daydose of 1 mg/kg/day

Non-stimulantsNon-stimulants Atomoxetine = Strattera (18 – 80 mg)Atomoxetine = Strattera (18 – 80 mg) Clonidine = Catapress (0.025 – 0.4 mg)Clonidine = Catapress (0.025 – 0.4 mg) Guanfacine = Tenex (0.5 – 2 mg)Guanfacine = Tenex (0.5 – 2 mg)


Stimulants work in 30 minutes; short acting preparations Stimulants work in 30 minutes; short acting preparations are dosed multiple times per dayare dosed multiple times per day

Stimulants improve attention/focus and decrease Stimulants improve attention/focus and decrease impulsivityimpulsivity

Common side effects include appetite suppression, Common side effects include appetite suppression, upset stomach, tics (reversible), tachycardiaupset stomach, tics (reversible), tachycardia

Need to monitor growth/weight in children and blood Need to monitor growth/weight in children and blood pressurepressure

Non-stimulant (atomoxetine) takes 2 weeks for effectsNon-stimulant (atomoxetine) takes 2 weeks for effects Non-stimulant (clonidine) causes a non-specific Non-stimulant (clonidine) causes a non-specific

decrease in hyperactivity and can be sedating; need to decrease in hyperactivity and can be sedating; need to monitor blood pressuremonitor blood pressure

Sleep MedicationsSleep Medications

Sleep Medications: these are many and varied Sleep Medications: these are many and varied in their effectivenessin their effectiveness

Sleep problems are complex issues and may be Sleep problems are complex issues and may be secondary effects of a psychiatric problem or secondary effects of a psychiatric problem or may be primary sleep disordersmay be primary sleep disorders

Remember, tiredness does not equate to the Remember, tiredness does not equate to the quality/restfulness/restorative nature of sleepquality/restfulness/restorative nature of sleep

Many medications cause sedation, but do not Many medications cause sedation, but do not improve sleep quality (and some actually improve sleep quality (and some actually interfere)interfere) Example: Benzodiazepines suppress REM sleepExample: Benzodiazepines suppress REM sleep


Trazodone = Desyrel (25 – 200 mg)Trazodone = Desyrel (25 – 200 mg) Melatonin (over the counter) (1 – 6 mg_Melatonin (over the counter) (1 – 6 mg_ Diphenhydramine = Benedryl (25 – 100 Diphenhydramine = Benedryl (25 – 100

mg)mg) Zolpidem = Ambien (5 – 20 mg)Zolpidem = Ambien (5 – 20 mg) Zaleplon = Sonata (5 – 20 mg)Zaleplon = Sonata (5 – 20 mg) Eszopiclone = Lunesta (1 – 3 mg)Eszopiclone = Lunesta (1 – 3 mg) Ramelteon = Rozerem (8 mg)Ramelteon = Rozerem (8 mg)


Most sleep aids produce sedation within 1 hour of taking themMost sleep aids produce sedation within 1 hour of taking them Some are designed only for initial insomnia and sedating effects Some are designed only for initial insomnia and sedating effects

wear off by 3-4 hourswear off by 3-4 hours Some are designed for middle insomnia and continue to cause Some are designed for middle insomnia and continue to cause

sedation up to 8 hours after takingsedation up to 8 hours after taking Continuous use can cause attenuation of sedating effect over timeContinuous use can cause attenuation of sedating effect over time Can be used for months at a time, but should prompt ongoing Can be used for months at a time, but should prompt ongoing

evaluation for underlying causes that are amenable to non-evaluation for underlying causes that are amenable to non-medication treatment (like sleep hygiene).medication treatment (like sleep hygiene).

Primary sleep disorders (apnea) need treatment with CPAP Primary sleep disorders (apnea) need treatment with CPAP (continuous positive airway pressure to prevent long-term (continuous positive airway pressure to prevent long-term complications (cardiopulmonary)complications (cardiopulmonary)

Treatment Approach to Treatment Approach to Developmentally Delayed Developmentally Delayed

IndividualsIndividuals Assessment (takes time)Assessment (takes time)

Current symptoms/behaviors of concern: Current symptoms/behaviors of concern: severity, duration, setting, triggersseverity, duration, setting, triggers

Psychiatric review of symtoms including Psychiatric review of symtoms including adaptive functioning, self-care, adaptive functioning, self-care, communication, social/school functioningcommunication, social/school functioning

Details of previous psychiatric treatment Details of previous psychiatric treatment including previous medications, response, including previous medications, response, side effectsside effects

Treatment Approach to Treatment Approach to Developmentally Delayed Developmentally Delayed

IndividualsIndividuals Assessment (cont.)Assessment (cont.)

Parent/Caregiver attitudes and long-term Parent/Caregiver attitudes and long-term plansplans

Review of prior psychological/cognitive testingReview of prior psychological/cognitive testing Past/Present educational/work and habilitative Past/Present educational/work and habilitative

functioningfunctioning Work programs, living situation, habilitative Work programs, living situation, habilitative

supportssupports

Multidisciplinary/Team ApproachMultidisciplinary/Team Approach

Due to complexity of caring for those with Due to complexity of caring for those with Developmental Disabilities, multiple care Developmental Disabilities, multiple care providers are usually involvedproviders are usually involved

Results in complex, interacting systems where Results in complex, interacting systems where communication is critical (both within and communication is critical (both within and outside of clinic setting)outside of clinic setting)

Communication with outside caretakers/teachers Communication with outside caretakers/teachers is often indirect (parent reports/letters)is often indirect (parent reports/letters)

Often, direct communication is neccesary/usefulOften, direct communication is neccesary/useful Constraints placed on patient confidentially or Constraints placed on patient confidentially or

parental preference can be barriersparental preference can be barriers

Multidisciplinary/Team ApproachMultidisciplinary/Team Approach

The PlayersThe Players Parents/Care ProvidersParents/Care Providers Child/Adolescent/Adult PsychiatristChild/Adolescent/Adult Psychiatrist Behavior SpecialistBehavior Specialist Case ManagerCase Manager Medical AssistantsMedical Assistants Primary Care PhysicianPrimary Care Physician GeneticistGeneticist Specialty Consultants (Pulmonologist/Neurologist/Rehabilitation)Specialty Consultants (Pulmonologist/Neurologist/Rehabilitation) Therapists (family, individual)Therapists (family, individual) Special Education TeachersSpecial Education Teachers Adaptive Therapists (speech/physical/occupational)Adaptive Therapists (speech/physical/occupational) Human services (Utah = DSPD and/or DCFS)Human services (Utah = DSPD and/or DCFS)

UNI H.O.M.E. Program (Healthy UNI H.O.M.E. Program (Healthy Options Medical Excellence)Options Medical Excellence)

UNI HOME Clinic

Behavioral/Psychiatric Services Case Management Primary Care

•Psychiatrist•Therapist

•Behavior Specialist•Group Therapists

•Liaison with school (teachers)•Liaison with DSPD

•Liaison with residential providers/families•Facilitate communication

•Treatment planning meetings•IEP reviews

•Letters•Specialist care coordination

•Advocacy

•Family Physician (focus on preventive care)•Nurse Practitioners (physician extenders)

•Nutritionist•Access to Habilitative Services(speech, physical, occupational)

Medical/School System InterfaceMedical/School System Interface

Barriers to CommunicationBarriers to Communication Legal – HIPPA (Health Information Portability Legal – HIPPA (Health Information Portability

and Protection Act): requires and Protection Act): requires parental/guardian permission to disclose parental/guardian permission to disclose protected medical informationprotected medical information

Geographic – school and clinic staff in Geographic – school and clinic staff in different locationsdifferent locations

Time – teachers and caregivers are busy Time – teachers and caregivers are busy (difficult to connect)(difficult to connect)


Unhelpful StancesUnhelpful Stances The demanding/entitled physician, teacher, or The demanding/entitled physician, teacher, or

parentparent The disparaging physician, teacher, or parentThe disparaging physician, teacher, or parent The undermining physician, teacher, or parentThe undermining physician, teacher, or parent The overwhelmed physician, teacher, or The overwhelmed physician, teacher, or

parentparent The indifferent physician, teacher, or parentThe indifferent physician, teacher, or parent


Constructive StancesConstructive Stances Open communication (invite parent/care Open communication (invite parent/care

providers/teachers into dialogueproviders/teachers into dialogue Capitalize on natural settings within each culture (IEP Capitalize on natural settings within each culture (IEP

meetings at school or treatment planning meetings at meetings at school or treatment planning meetings at a clinic)a clinic)

Discuss expectations ahead of time to avoid Discuss expectations ahead of time to avoid disappointmentdisappointment

Review interventions regularlyReview interventions regularly Utilize technology/variety of communication forms Utilize technology/variety of communication forms

(letters, e-mail, video tape (with consent), phone, (letters, e-mail, video tape (with consent), phone, rating scales)rating scales)

Be flexibleBe flexible


Practical Advice for Special Education TeachersPractical Advice for Special Education Teachers Be open to observing/documenting behaviors in the Be open to observing/documenting behaviors in the

classroom in the context of ongoing treatmentclassroom in the context of ongoing treatment Allow yourself to be a blinded observer and complete Allow yourself to be a blinded observer and complete

requested rating scalesrequested rating scales Communicate concerns about effects of medication Communicate concerns about effects of medication

(side effects such as sedation or agitation) to parents(side effects such as sedation or agitation) to parents Don’t tolerate the sedated/sleeping child who isn’t Don’t tolerate the sedated/sleeping child who isn’t

disruptivedisruptive Guide clinicians/parents in their advocacy effortsGuide clinicians/parents in their advocacy efforts Be over vigilant with sensitive psychiatric or mental Be over vigilant with sensitive psychiatric or mental

health informationhealth information


Practical Advice for Special Education TeachersPractical Advice for Special Education Teachers You know the child’s educational style/behavior in the You know the child’s educational style/behavior in the

classroom better than anyone elseclassroom better than anyone else Communicate observations of social and learning Communicate observations of social and learning

interactions impartially, but accurately (avoid using interactions impartially, but accurately (avoid using extreme descriptions which can be misleading)extreme descriptions which can be misleading)

Utilize existing resources within the school system Utilize existing resources within the school system (school psychologist)(school psychologist)

Advocate within your school for the resources you Advocate within your school for the resources you need to do your jobneed to do your job

psychiatry treatment in individuals with developmental delays philip l. baese, md assistant clinical...

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