the role of medications and other biological approaches in early childhood mental health (we can't...

7/27/2019 The Role of Medications and Other Biological Approaches in Early Childhood Mental Health (We Can't Wait Sept 2013)

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Director of Research, Graduate School,Interdisciplinary Council on Developmental

and Learning Disorders

Assistant Clinical Professor, Voluntary

Department of Psychiatry,

University of California at San Diego

School of Medicine

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Disclosures, Fall 2103

Clinical - 50% time, 99% of income

SymPlayipad/ UCI research

ICDL Grad School: math, research

Early Yearspeace building

COC state advocacy for EBP

BRIDGE early intervention

Circlestretch community resource

Cherry Crisp media company


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Learning Objectives

Name the three core principles of Evidence

Based Practice.

Name and Describe three basic levels of a

developmental social-emotional function.

Understand that medications may help in

Infant and Childhood Mental health but that

they do not replace a good overall plan.


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Evidence Based Medicine/ PracticeThe bio-psychosocial model & DIR

Medicine and other biological approaches

Outline(Partial Bait & Switch)

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Dont sweat the details - this talk will be posted

on

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Where to start? Its a big universescientific knowledge is a lot smaller than nature

and we often dont have exact answers of what to do

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If we dont know exactly what to do,

how Do We Decide What to Do?

Evidence Based Practice

From Sackett 1996 to American Academy of

Sciences Institute of Medicine 2001 to

Buysee 2006 (IMH), and through to today

(Brandt, Deil, Feder, Lillas 2013)

The combination ofrelevant research with

clinical judgment and experience to

provide families with the information to maketruly informed consent decisions based on

their own family culture and values.


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Striving for balanced thinking:

Too much reliance on a research paper mightnot make sense (teaching to point to coloredsquares), or might not be appropriate for

family (e.g. separation of child from parent) Too much reliance on clinical experience

alone might lead to use of ineffectiveapproaches and poor results (e.g. wait and

see for toddlers at risk for disorders ofrelating and communicating, overuse ofantibiotics for ear infections)


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the three core principles of Evidence Based Practice


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We want to figure out how to help

infants and young children

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For starters:

Theres no such thing as a baby


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Minimum Meme = baby+caregiver


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Similarly


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We can only

understand a child in context


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When we think about

helping a child function better


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We need to think about

supporting caregivers


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Biological Psychological Social

George Engel: cardiac care

Carl Whittaker: the buffy coat

Its Complicated:

Bio - Psycho - Social

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Covers a broadening range of possible

influences

Gets you thinking about all the factorsinvolved

Brainstorm with BPS as your guide

Its Complicated:

Bio - Psycho - Social

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Examp e: Ba y s not s eeping


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Spiritual Big Bang (OMG!)

Galactic: solar, gamma rays (Courchesne)

Global: Environmental (Japan radioactivity?, rising tides?), Geopolitical (dad at war)

National: Environmental (weather systems, wild fires); Political (ACT Today)

Regional: Microenvironmental (dry air; CA autism clusters & SES); State cuts

Local: Environmental (artillery exercises, red tide); Political (school district pink slips)

Extended Family: far away; Ghosts; some with genetic (?) issues; babysitter issues?

Immediate Family: Dad deployed, mom isdown

and exhausted, worried about SIDS

Child: responses to not getting much good mom time (anaclitic?); other (DMIC)

General biological: not sleeping well, not eating well, hydration, medications

Organ systems: teething, CNS, GI, Immune (OM?), Skin (rash), Hepatic, Renal, injury

Cellular: DNA, RNA, mitochondrial function, insulin resistance

Biomolecular: receptors and intracellular signaling (histamine, serotonin, etc.)

Inorganic molecular/elemental: lead. CO, CO2, post fire particulate matter

Atomic and subatomic: gamma rays, 11 dimensional universe

Examp e: Ba y s not s eepingBPS/SPB

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Its Always So Complicated -

We need an OrganizingPhilosophy


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Using DIR as an Organizing

Philosophy for a BPSDevelopmental Approach

Broad whole child, supports family Welcoming all about building love

Enriching closeness can bring progress


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DIR in a nutshellStanley Greenspan & Serena Wieder

Developmental levels from regulation,to warm trust, and then a flow of enriching

interactions

Individual Differences sensory, motor,communication, visual-spatial, cognitive,

etc.

Relationship Based all aboutconnecting, and making time with others

for support and help


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Developmentalthree basic levels of a developmental social-emotional function

I. Regulation calm and alert

II. Engagement truly connected

III XV. Reciprocity flow of interaction

that is gradually more complex and

abstract


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Regulation - Calm and Alert

Most basic requirement of all

We (the world) need to help parents be calm so

child can be calm - support, therapy, medication

for parent? How able is the child, developmentally?

Homeostasis arousal level & stability

Does child have specific problems that

medication might address to help the child beregulated (attention, impulsivity, over-

aroused/hypervigilant, low arousal, seizures

etc.)?

Engagement Truly


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Engagement Truly

Connected Affective connection drives internal motivation for

communicating and learning if you dont care, youdont think and adapt

Help parents to be emotionally present and to find or

create loving moments

How able is the child, developmentally? Needs to be

regulated; childs repeated repair of engagement

brings resilience (Tronick)

Does child have specific problems that medication

might address to help the child (e.g., failure of

natural positive exploratory attitude depression,

anxiety, etc.?)


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Reciprocity - Flow of

Interaction Circles of interaction, many of them in the

course of solving the social problem of the

moment (eating, playing, toileting, learning, etc.)

Help parents build on the childs lead to create a

shared, meaningful experience

How able is the child, developmentally? Needs

to be regulated, engaged, to respond, repair

Does child have specific problems thatmedication might address to help the child (rigid

or negative thinking, irritability, etc.?)


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AssessmentObservations:

Child physical, behavioral

Relationships with caregivers

In office, at home, in other care settings, class, activities

Other Information to consider:

Collateral information from other caregivers, teachers,

health care providers (OT, PT, speech, etc.)Review of records medical, preschool, etc.

Laboratory studies


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DIR Summary of Assessment

Developmental: stability of capacity forRegulation- Engagement Reciprocity

Individual Differences: qualities of childs

Sensory motor receptive expressive visual exec

Executive: idea, plan, steps, execute, adapt

Relationship: caregiver abilities to

Comfort - calm & alert; engage; read cues respond

support developmentWhat does the support system look like?


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From Assessment to Intervention

Developmental:Supporting Regulation- Engagement Reciprocity

Individual Differences:

Other Therapies (OT, PT, SL, Ed, etc.)

Medications and other biological approaches

Relationship:

Coaching parents &caregivers

Shoring up support systems: safety, reflectiveopportunities, reflective institutions


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From Assessment to Intervention

Developmental:Supporting Regulation- Engagement Reciprocity

Individual Differences:

Other Therapies (OT, PT, SL, Ed, etc.)

Medicationsand other biological approaches

Relationship:

Coaching parents &caregivers

Shoring up support systems: safety, reflectiveopportunities, reflective institutions


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Medications

and other biological approaches


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Medication and Other Approaches

For Our Family

Brainstorm ideas, then sort, prioritize

Safety first!

BPS becomes SPB social supports typically needed to

make anything else work, e.g., no meds withoutinsurance, organization, caregiver support

Other therapies typically come before meds, e.g.sensory based OT (exceptions include seizures, asthma,

infections, etc.) When the rest of the plan is in place and if things stillarent going well, then we should consider medications


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Complete workup: consider (24 hour) EEG, labs, etc. along with

complete history, physical, t ime with th e chi ld and fami ly, and collateral informationfrom school, therapists, etc.

Diagnosis: a hypothesis meant to focus treatment, as well as other possible &co-occurring diagnoses. The 5 axis system helps, and new dimensional axes may workbetter Build the care plan: and once that is in place, if it appears

medicaiton may help then

Grid and prioritize target symptoms and possibletreatments and fill in likely +s & -s, in a flexible decision matrix

Availability- provider MUST stay in touchwith family and school

GOLDEN RULE: think carefully before rapid, largechanges in dose or before changing more thing

than one thing at a time.

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Name Your Symptoms

Activity,impulsivity

Anger Attention

Anxiety, specificfears Cognition Depression Eating Elimination GI Distress Moodinstability,

irritability,

aggression

Motor tone Motor Planning

O/C, rigidityPerseverative

Pain Reciprocal

interaction

Seizures Sensory

Sensitivity &

Processing

Sleep Tics Trauma s/s

Others??

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Infants and Young Children are Different


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Liver: enzymes (more of some, less of others), liver to body ratioPlasma: more relative body water

Plasma protein binding is reduced fetal albumin less binding

Less fat and so less lipid filling, release, etc.

Kidney glomerular filtration is not fully developed at birth: adult by2 (more changes in adolescence)

Brain: fewer neurons and far fewer dendrites with different size,construction, tracts, & receptors; BBB is more permeable

Gastrointestinal pH is acidic in neonates: acidic medication absorb

well, more base ones do notSkin, eye membrane permeability is increased (think toxins)

Infants and Young Children are Different


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Look it up


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Moms meds through placenta or breastfeeding

Anti Epileptic Drugs: for seizures dangers of polypharmacy

Steroids: usually for seizures - side effects problematic

Neuroleptic (antiosychotic) cousins in gastrointestinal

treatment

Lithium early in the bipolar child literature

Stimulants PATS: the first large scale prospective study of

psychotropics in preschoolers

History of psychotropic use in

Infants and Young Children:

Evidence Based Practice and


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Research is limited, but may be supportive. We borrow from adultworld but this is not necessarily appropriate to do

Clinical experience typically suggests we start low, go slow, and trynot to change more than one thing at a time.

Family Culture and Values might lead to request for medication

when we are not comfortable (e.g. no bigger plan in place or tryingto have a child conform to a harsh regime at home or school) orshunning them when we feel they might be very helpful or evenvitally important (e.g. clear severe bipolar).

Informed consent Parents should almost always be the actual

decision makers. Ethical, rational approaches often require lots oftime to talk and think things through together in a reflective andongoing process throughout the course of care

Evidence Based Practice and

psychotropic use in

Infants and Young Children:


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Regulation and co-regulation by treating, e.g., attention,impulsivity, over-aroused/hypervigilant, low arousal, etc.also treat seizures, esp. absence seizures.

Engagement: Widen availability for and tolerance ofemotions so the person is less likely to become

overwhelmed, withdraw; more able to maintainengagement failure of natural positive exploratoryattitude depression, anxiety, etc. Better able to repairand build resilience over time.

Reciprocity: Treat co-occurring conditions/ symptoms,

e.g., negative thinking, irritability; mood stability, rigid

thinking, perseveration. Mightpromote abstract

reasoning and thinking.

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Targets

Activity

Attention

Anxiety

Cognition

Depression

Mood

Instability

aggressio

n

Motor

Planning

O/C,

rigidity

Perseverative

Reciprocal

interaction

Sensory

Sensitivity

Tics

Sleep

Etc

Comments

Stimulants +/- +/- - +/- - - +/- - +? - - - Wt

Ht

tics

SSRIs - - +/- -/+ +? -/+ +? +? -/+ Wt, Ht

Sz

Neuroleptics +? -? + -/+ +? ++? - +? ++?? +? + + Wt. Sz

TD

NMS

AEDs +? -/+ + -

/+?

+? ++? -? +? +? +? +? +/- Mult.

SE

Central AlphaAgonists

+? +? +? -/+ +/- 1/+? -/+? +? +? +? +? + SleepBP

Etc

LIST OTHER

TREATMENTS!


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Stimulants

Methylphenidate: Ritalin, Concerta, Metadate,Methylin, Focalin, Daytrana Patch, Quillivant liquid

Dextroamphetamine: Adderall, mixed salts, Vyvanse

Slightly different mechanisms.

Similar possible side effects: appetite, sleep,withdrawal, depressed mood, unstable mood, tics,obsessiveness, etc. Get a cardiac history, maybe anEKG.

Drug diversion vs. drug abuse risk ADHD and ASD

Often makes a good plan workable.

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SSRIs

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

likely obsessiveness (although works well for that forneurotypicals)

Prozac (fluoxteine), Zoloft (sertraline), Paxil (paroxetine),

Luvox (fluvoxamine), Celexa & Lexapro (citalopram). Similar possible side effects: behavioral activation,weight gain (and loss), mood instability, lower seizurethreshold, etc.

Drug-Drug interactions & Serotonin Syndromesweating is often the first sign

Black box warning misleading: suicide rate had beendropping, then the warning in 2004 led to reducedprescriptions and higher rates of suicide.

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Neuroleptics

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

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

Helping aggression, mood stability, and miracles? As well astics, and adjunct for depression, perseveration, etc.?

Monitor weight ,fasting lipids, and fasting glucose, as well as

for seizures, fevers (NMS) and new abnormal movements(TD), stroke (elderly), cardiac

Should we always consider neuroleptics in ASD?

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Abnormal Involuntary Movement Scale (AIMS)

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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

Many kids on the spectrum have seizures! Might help other medications work better (stimulants,

antidepressants)

Combined pharmacology vs. polypharmacy

Sudden stopping might make seizures more likely

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Specific AEDs

Depakote (valproic acid, valproate) pretty reliable, easy

to load, watch levels, platelets, bruising, liver, pancreas,

carnitine, menstrual irregularities, weight, sedation.

Problems when using with Lamictal

Tegretol (carbemazepine) - ?reliable, watch levels, bloodcounts, EKG, lots of drug interactions, induction of

hepatic enzymes, weight gain, sedation, rash

Trileptal (oxycarbezepine)Tegretol light?; motor

problems, electrolyte issues, rash?

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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 rashStevens Johnson Syndrome

Topamax (topiramate) adjunct, may cause weight loss, loss

of expressive language, usually need to go slow. May beuseful for addiction, Tourettes, OCD.

Neurontin (gabapentin) Does it work at all? Does it harm at

all? Does help pain syndromes, maybe anxiety too.

Lyrica (pregabalin) for pain in fibromyalgia, partial seizures Zarontin (ethosuccimide) for partial/ absence seizures; liver

issues

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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

Maybe get an EKG for clonidine?

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Oth C l C id d


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Other Commonly Considered

Medications

Straterra (atamoxetine) for ADHD; may be as good asplacebo, may act like an antidepressant (+/-)

Wellbutrin (bupropion, etc.) dopaminergic, weight, loss,sleep loss, irritability, seizure risk, headache risk

Rozerem (ramelteon) melatonin agonist SNRIs Effexor (venlafaxine), Cymbalta (duloxetine),

Remeron (mirtazepine), Serzone (nefazedone), Pristique(desvenlafaxine). Watch for withdrawal.

Deseryl (trazodone) antidepressant often used forsleep; cognitive side effects, priapism

Buspar (an azaspirone) mild, serotonergic crossreactions

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More Others

Lithium great mood stabilizer; anti-suicidal;bipolar-ASD connection; levels, thyroid, kidneyfunction; blood levels, NPH (wet, wild &wobbly)

Namenda (memantine) Alzheimers medantagonistof the N-methylD-aspartic acid(NMDA) glutamate receptor, thisdrug washypothesized to potentially modulate learning,

blockexcessive glutamate effects that caninclude neuroinflammatoryactivity, and influenceneuroglial activity in autism

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Meds I avoidat all ages

Paxil (paroxetine), Effexor (venlafaxine), Cymbalta (duloxetine)- withdrawal

Tegretol (carbemazepine) hard to make it work

Combo Depakote and Lamictal levels unwieldy

Tricyclics Tofranil (imipramine), Norpramin (desipramine),Pamelor (nortriptyline); and, esp. good for typical OCD,Anafranil (clomipramine). Cardiac, blood pressure issues.

Monoamine Oxidase Inhibitors Nardil (phenelzine) , Parnate(tranylcypromine), Marplan (isocarboxazide), Emsam(selegiline) can be useful although dietary, blood pressuredrop and hypertensive crisis must be considered; lots of drug-drug interactions

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More on clinical experience


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More on clinical experience

Usual general guidelines

Start low, go slow

Try not to change more than one thing at a time,

including meds, placements, etc.

Give things enough time to work, to workthemselves out

Always have a next appointment and a way to stay

in touch

Always keep the bigger plan in mind if meds

arent working is there something else going on?

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No one should work alone

All suicidal/homicidal ideation is serious

Look for interactions ask aboutsupplements, etc.

Sweating, ataxia, loss of bladder control

Blood pressure whats right for age?

Abuse, unusual boundaries

Treating people you already know

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Potions, etc.

C H h ld 'P i '


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Breast milk: mother of them all- from preventing

illness through antibodies to improving cognitiveoutcomes and reducing rates of later conductdisorder

Hydration and sports drinks (fructose/

electrolytes).Chicken soup for colds

Gatorade for rehydration - fructose andelectrolytes

Tea and honey (and whiskey?) for sore throatsCoffee - reduces depression in women

Whiskey on gums for teething

Common Household 'Potions'

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Various Common Supplements


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Herbs: parsley for digestion and better breath

Minerals: zinc: may prevent depression; chromium mayhelp depression

Omega 3 fatty acids Eicosapentaenoic Acid (EPA) andDocosahexaenoic Acid (DHA) for depression and for moodstability, as well as to protect against Tardive Dyskinesiawith neuroleptics

Amino acids: inositol (depression, schizophrenia); D-cycloserine (OCD); L-tryptophan (sleep)

Vitamins: D3 (depression, etc.), B vitamins (relief ofstress); Niacin (B3): reduces cholesterol, triglycerides.

Really Bad ones: bath salts (mephedrone), THC -psychosis risk, loss of hippocampal cells

Various Common Supplements

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Other Available Means


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Exercise: helps depression, anxiety; yoga; Tai Chi

Sleep (also a future lab dont pick this one)

Meditation: helps depression, anxiety, pain

Light: Sunlight: serotonin; Blue and green light: blue

can keep you up, blue and green both can changeemotional processing in persons with Seasonal

Affective Disorder

Music: Mozart, Bach, etc. Cultural. Minor vs. Major

keys. Music therapy does improve depressive

symptoms in the moment.

Other Available Means

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Summary:


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Organize your thinking around Regulation,

Engagement and Reciprocity, what the world can doto help parents support these capacities in children.

Look at what research there is, use your experience

to think about what makes sense, and help families

make ongoing informed decisions based on their own

culture, values, and development.

Medications do not make up for a bad plan, but they

might help a good one to succeed.

Summary:

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Working Together for

Parent Choice!

Come to Burbank October 18 19, 2013!

dirfloortimecoc.com


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Your Experiences?

the role of medications and other biological approaches in early childhood mental health (we can't...

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