Focused?

Front Line Management of Behavioral Health Conditions

Joshua D. Feder MD, Director of Research, Interdisciplinary Council on Developmental and Learning Disorders Associate Professor, Voluntary, Department of Psychiatry UCSD School of Medicine

Disclosures, Fall 2103

Clinical - 50% time, 99% of income SymPlay ipad/ UCI research ICDL Grad School: math, research Early Years peace building COC state advocacy for EBP BRIDGE 1,.15m in grants Circlestretch community resource Cherry Crisp media company

Dont sweat the details - this talk will be posted on

The Situation

The Situation
20% of kids have a behavioral health condition 1/10th of those get treated Many symptoms, many diagnoses: Examples: ADHD + learning disorder + anxiety or mood or oppositional, social difficulties Autism Spectrum with sensory, motor, mood, learning, perseverative, etc Teen with mood, substances, & abuse history

Whats Common
ADHD 5% of kids Mood disorders 4%, 33% lifetime risk Autism Spectrum Disorder 2% Anxiety 1% (+) in kids, more with age Severe substance issues 1% (+), spike in teens Etc Earlier Onsets = Nastier Problems

Areas of Function to Check

for Common Psychosocial Problems

HEADS
Home: relationships, culture & values, abuse Education: grades, activities, peer issues Activities: peers, sports, clubs, community Drugs: and medications, herbals, diets Sex: identity, exposure, intimacy

Your Possible Roles

Assessment: Medical check, lab studies, & referrals Behavioral symptoms checklists DSM 5 What the child tells you, shows you Time to talk to family, teachers, etc. Management: Supporting the child in the office & beyond Continuing medication for a stable patient When to ask for help

Assessment
Bio physical, maybe labs Psycho look at symptoms Social home, school, activities

Humiliation is Damaging

Make other time to talk

Make time Save Time*

*You get important information for treatment. Bonus: Specific plans for follow up calls and appointments reduce family anxiety

Getting kids to talk

Front load time - pays off later Stay calm, then they are more calm Some tell all, some never talk dont force it Statements may work better than questions So I hear youve been upset. We can figure this out Body language try to read their cues ask parents! Some have strong feelings but dont show them

Avoid talking about kids with parents in front of the child or teen - call before or after if necessary

Eye level, stay calm, give some time

In Office Therapy? Help set up try, & try again

Goal: repair connections with others, over and over to build competence, confidence, & resilience Take time and listen - take their word for it Get their ideas: Tell me what you think might help Set up check in over and over* to try other things Resources online ideas, etc.
*with you, parent, teacher, coach, therapist, mentor, etc.

Relationships matter!

Well win some, and well lose some Thats ok - lets keep trying

Management
Bio exercise, maybe meds, maybe labs Psycho building better problem solving Social home, school, activities
Adult presence is key: balanced mix of support and expectations is critical to a good outcome

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

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 work better

complete history, physical, time with the child and family, and collateral information from school, therapists, etc.

Grid and prioritize target symptoms and possible treatments and fill in likely +s & -s, in a flexible decision matrix Availability - provider MUST stay in touch with family and school
GOLDEN RULE: think carefully before rapid, large changes in dose or before changing more than one thing at a time.
19

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 of relevant research with clinical judgment and experience to provide families with the information to make truly informed consent decisions based on their own family culture and values.

Balanced thinking:
Too much reliance on a research paper might not make sense (teaching to point to colored squares), 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 ineffective approaches and poor results (e.g. wait and see for toddlers at risk for disorders of relating and communicating, overuse of antibiotics for ear infections)

22

Name Your Symptoms

Activity, impulsivity Anger Attention Anxiety, specific fears Cognition Depression Eating Elimination GI Distress Mood instability, irritability, aggression Motor tone Motor Planning O/C, rigidity Perseverative Pain Reciprocal interaction Seizures Sensory Sensitivity &

Processing Sleep Tics Trauma s/s Others??

23

O/C, rigidity Perseverative

Mood Instability aggression

Depression

Reciprocal interaction

Stimulants

+/-

+/-

+/-

+/-

+?

Wt Ht tics Wt, Ht Sz Wt. Sz TD NMS Mult. SE Mult SE

SSRIs Neuroleptics

+?

-?

+/+

-/+ -/+

+? +?

-/+ ++? -

+? +?

+? ++?? +? +

-/+ +

AEDs Steroids

+? -?

-/+ -?

+ +?

/+? +?

+? -/+

++? -?

-? +?

+? -?

+? ++?

+? -?

+? +?

+/-?

Central Alpha Agonists

Etc LIST OTHER TREATMENTS!

+?

+?

+?

-/+

+/-

1/+?

-/+?

+?

+?

+?

+?

Sleep BP

Comments
24

Sensory Sensitivity

Cognition

Attention

Motor Planning

Activity

Anxiety

Targets

Sleep

Etc

Tics

 Support regulation and co-regulation by

treating, e.g., impulsivity, inattention, anxiety, rigid thinking, perseveration.

Widen tolerance of emotions so

the person is less likely to become overwhelmed.

Treat co-occurring conditions,

e.g., depression in ADHD, irritability in ASD.

Might promote abstract reasoning and thinking.

25

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 an EKG. Drug diversion vs. drug abuse risk ADHD and ASD Often makes a good plan workable.
26

SSRIs
One of many classes of antidepressants Can really help depressed mood, maybe anxiety, less likely obsessiveness (although works well for that for neurotypicals) Prozac (fluoxteine), Zoloft (sertraline), Paxil (paroxetine), Luvox (fluvoxamine), Celexa & Lexapro (citalopram). Similar possible side effects: behavioral activation, weight gain (and loss), mood instability, lower seizure threshold, etc. Drug-Drug interactions & Serotonin Syndrome sweating is often the first sign Black box warning misleading: suicide rate had been dropping, then the warning in 2004 led to reduced prescriptions and higher rates of suicide.

27

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 for symptoms of psychosis. Helping aggression, mood stability, and miracles? As well as tics, 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?
28

Abnormal Involuntary Movement Scale (AIMS)

29

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

30

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, blood counts, EKG, lots of drug interactions, induction of hepatic enzymes, weight gain, sedation, rash Trileptal (oxycarbezepine) Tegretol light?; motor problems, electrolyte issues, rash?

31

More AEDs
Keppra (levetiricetum) easy to use, but does it work? Lamictal (lamotragine) mood stability, ?better mood. Must go slow, and watch for rash Stevens Johnson Syndrome Topamax (topiramate) adjunct, may cause weight loss, loss of expressive language, usually need to go slow. May be useful 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

32

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?
33

Other Commonly Considered Medications

Straterra (atamoxetine) for ADHD; may be as good as placebo, 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 for sleep; cognitive side effects, priapism Buspar (an azaspirone) mild, serotonergic cross reactions
34

More Others
Lithium great mood stabilizer; anti-suicidal; bipolar-ASD connection; levels, thyroid, kidney function; blood levels, NPH (wet, wild & wobbly) Namenda (memantine) Alzheimers med antagonist of the N-methylD-aspartic acid (NMDA) glutamate receptor, this drug was hypothesized to potentially modulate learning, block excessive glutamate effects that can include neuroinflammatory activity, and influence neuroglial activity in autism
35

Meds I avoid
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 pressure drop and hypertensive crisis must be considered; lots of drugdrug interactions

36

Special Caution on Benzodiazepines!

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
37

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 work themselves out Always have a next appointment and a way to stay in touch

38

 No one should work alone All suicidal/homicidal ideation is serious Look for interactions ask about supplements, etc. Sweating, ataxia, loss of bladder control Blood pressure whats right for age? Abuse, unusual boundaries Treating people you already know
39

Look at the whole picture, take time to think Be careful with meds Think repair Never work alone

40

Your Experiences?