Joshua D.

Feder, MD October 28, 2011 Tel Aviv, Israel

Redacted for Posting

Case material removed Questions? email jdfeder@pol.net

Director of Research, Graduate School, Interdisciplinary Council on Developmental and Learning Disorders Assistant Clinical Professor, Dept of Psychiatry, University of California at San Diego School of Medicine
3

ICDL Graduate School

ICDL Southern California Regional Institute

NIMH/ Duke University/Pfizer SymPlay, LLC
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Feder 411
Math, Engineering, and Developmental Disorders beginning 1978. US Navy Child Psychiatry Mike 1990 (1992) Greenspan and Wieder 1993 Career expansion: clinic, teaching, research, advocacy, tech development and arts & media.

 The

DIR/Floortime Model Reflective Process Support for the DIR Model Considering medication Case examples Your experiences
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But First, Some Commercials

Because we build ideas together And you can join us in the effort!

Working Together for

Parent Choice!
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The Southern California DIR/Floortime Regional Institute

Pasadena, California February 24-26, 2012

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Thank You!
Families say a silent thank you Greenspan & Wieder Mara Goverman Daniel Carlat David Sackett (et. al.) Ricki Robinson Michael Chez So many others

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Assumptions
Varying familiarity with DIR/Floortime and the supporing research. Varying understanding of Evidence Based Practice

15

Conclusions:
The program is paramount. Reflective process is the key to a good program. Medication might help a good progam work better

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Why DIR? because its

Broad whole child, supports family Welcoming all about building love Enriching closeness brings progress in relating, communicating, and thinking

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Taking Notes?
One

word:

ENGAGEMENT
goes beyond compliance

Engagement Connection

before correction

DIR quick guide

Developmental - regulation, warm trust, then a flow of enriching interactions Individual Differences sensory, motor, communication, visual-spatial, cognitive Relationship Based connecting and supporting at many levels

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Quality of Caregiver-Baby Relationship Matters

D.W.

Winnicott

There is no such thing as a baby A baby cannot exist alone, but is essentially part

of a relationship
Relationships

are central to development

Affect = Emotional Connection

The glue that organizes all of the jobs of the brain Coordinates the nervous system from the brain outward Lends purpose and meaning to the information we take in through our senses Emotional based learning experiences become an internal reinforcement that motivates

Theory Behind DIR

Affect is the central organizer of experience in all developmental domains Experience is dual coded in the sensory system and the affect cueing system Individual differences in processing sensory motor information impact how parents and children make meaning from their interactions and from expectations about their relationships

Individual Differences
Sensory modulation and processing Postural control and motor planning Receptive communication Expressive communication Visual-spatial funciton Praxis: knowing how to do things to solve the social problem of the moment

Things to Keep in Mind

Hypo-reactive (decreased sensitivity) Sensory seeking Does not register input or has delayed responsiveness to sensory input Hyper-reactive (increased sensitivity) Sensory avoiding Associated with increased reactivity to sensory input (fight/flight/fright responses) Mixed Hypo/Hyper-Sensitivity: common

Caregiver Patterns and Child Development

Sensitive responsiveness Attunement Mutually confirming interactions

Mirroring, Matching, Expanding

Attachment
Secure, Anxious, Avoidant, Chaotic, Aloof

Relationship Classification
Overinvolved Underinvolved Anxious/Tense Angry/Hostile Mixed Relationship Disorder Abusive (verbal, physical, sexual)

More to the point:

Joint attention responsive (cured), initiated (when we wait for it) Intent Engagement Repair (Tronick)

These are at the core of the moment to moment affective reciprocity that supports the developing relationship.
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Functional Emotional Developmental Levels

I II III co-regulation, ability to attend, interest in the world engagement, attachment, gleam in the eye, warmth circles of interaction, purposive two way communication IV flow, social problem solving, behavior organization V symbolic thinking (critical shift) VI logical connections between ideas (what, when, how, and why questions) VII multicausal thinking VIII grey area thinking IX reflective thinking, stable sense of self, and an internal standard

I - Calm enough: (Coregulation)

Know We Not

the person: individual differences

do this together a sensory break (= escape)

Reach Calm Think

wth 80% intensity to help the person calm down with you. enough might mean active enough. about what works and what doesnt work

II - Truly Connected to Others (Engagement)

That gleam in the eye Mostly fun and feels good for everyone creates the bond that will leads to learning Joint attention, but joyful

III Circles: back and forth interaction

The

person is always doing something

the childs lead - Join in - be part of the activity Improv = yes If you cant just join in, gently and playfully get in the way
Follow If

he wants something, he has to get it from you

IV Flow

(and avoiding questions)

Chains of 20-40 circles Expanding complextiy Questions make people close up or act mad Statements create social problems that the other person can solve Try it out. Its hard, but worth the work

Things to Avoid

Dont just entertain, quiz, or direct the child with your games, demands, or ideas Dont merely follow the child around use the child lead to start off Every idea is a good one to play with dont say no to the idea - connect and play with it. You can set limits as needed.

What about other kids?

Start with adults Build some skills Semi-structured activities with peers Limiting numbers of kids Mediate the process slow it down Statements more than questions Democratic decision making

Things you might say or do:

We need to figure out what to do I need help with Wait - I didnt hear you We can vote on whether he was out.. Semi-structured: at times you direct things, but work toward less of it. In free play, you join the person in a way that attracts other kids, then facilitate the mix

Likert Scale for Each Level

Not doing it 2. Barely able to do it 3. Islands of time where the child can do it 4. Can expand those islands with our help 5. Comes back for more with little or no support 6. Pretty normal unless under stress 7. Age appropriate
1.

Family /Caregiver Patterns:

Comforting Finds appropriate level of stimulation Engages in relationship

Reads cues and signals

Maintains affective flow (for coregulation)

Encourages development

The Learning Tree

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Summary: Why DIR?

It is BPS, and BPS is good We can change outcomes despite genetics. Affect is the key - this is affect based Beyond behavioral treatments Medication can only support treatment There is Evidenced Based Research to support it

Research Support for DIR/Floortime Macro: comprehensive interventions Odom, et al. there is no one winner .. Care reports, single case studies Salt, Mahoney PLAY Pajareya York Micro: core concepts Joint attention Parent coaching Repair

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Evidence based medicine, and informed consent

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Reflective Process
There

are always new challenges Nothing goes as expected Caregivers rarely have the support and time they need to think Make time a moment to listen.

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Reflective Process: in the moment

Humility:

you do not have the answer Facilitate problem solving Wonder about the situation Track the emotion, then and now Statements vs. questions. Empowering vs. dictating.

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Reflective Process: regular contact

Selling the idea of making another moment can we make an appt to check in later? Set another time to check in.

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Medications

Rationale for using medication: last resort vs. covering all bases

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Controversies about medications in developmental and learning disorders:

Stimulants Antidepressants core symptoms overmedication

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Specific Medications
For details see circlestretch.com For a framework, see The Learning Tree (+caregiver profile)

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Remember the Tree

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Individual Differences Charlie Preschool 5/05 & Kindergarten 9/05

Sensory Postural Response to Communicatio n
Trouble managing more than one thing at a time 1. Orient 2. key tones

Intent to Communi cate

Visual Exploration
Distractible. 1.focus on object ---- 05/05---2. Alternate gaze 3. Follow anothers gaze to determine intent. 3. Switch visual attention 4. visual figure ground 5. search for object 6. search two areas of room

Praxis -

Sensory seeking, distractible Auditory Visual Tactile Vestibular Proprioceptive Taste Odor

Low tone; A bit clumsy impedes rapid reciprocity in the moment 1 indicate desires 2. mirror gestures 3. imitate gesture ---- 05/05---4. Imitate with purpose. 5. Obtain desires 6. interact: - exploration - purposeful -self help -interactions

Dysarthric Logical discourse is Difficult 1. Mirror vocalization 3. key gestures s 4. key words 2.. Mirror ---- 05/05---gestures 5. Switch auditory 3. gestures attention back 4. sounds and forth 5.Words 6. Follow ---- 05/05--directions 6. two word 7. Understand 7. W ?s 8.abstract Sentences conversation. 8. logical flow.

Easily frustrated Ideation -- 05/05--Planning (including sensory knowledge to do this) Sequencin g Execution Adaptation

7. assess space, shape and materials. -

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Individual Differences Charley First Grade

Sensory Postural Response to Communicatio n
Trouble managing more than one thing at a time 1. Orient 2. key tones

Intent to Communi cate

Visual Exploration
Distractible. 1.focus on object 2.----3/07---2. Alternate gaze 3. Follow anothers gaze to determine intent. 3. Switch visual attention 4. visual figure ground 5. search for object 6. search two areas of room

Praxis -

Sensory seeking, distractible Auditory Visual Tactile Vestibular Proprioceptive Taste Odor Taste and odor are better

Low tone; A bit clumsy impedes rapid reciprocity in the moment 1 indicate desires 2. mirror gestures 3. imitate gesture 4. Imitate with purpose. ----3/07---5. Obtain desires 6. interact: - exploration - purposeful -self help -interactions Much better postural control

Dysarthric Logical discourse is Difficult 1. Mirror vocalization 3. key gestures s 4. key words 2.. Mirror ----3/07---gestures 5. Switch auditory 3. gestures attention back 4. sounds and forth 5.words 6. Follow ----3/07---directions 6. two word 7. Understand 7. W ?s Sentences 8.abstract conversation. 8. logical flow. Stronger foundation NOT CHANGED

Easily frustrated Ideation Planning (including sensory knowledge to do this) ----3/07---Sequencin g Execution Adaptation

7. assess space, shape and materials.

Can focus pretty well on an object now

A step forward..

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52

Sample Full FEDL (Charlie)

Not there Barely
3/06 3/06 3/06, 3/07 3/06 3/06 3/06 3/06, 3/07 3/06, 3/07, 3/06, 3/07 3/07 3/07, 3/08 3/07, 3/08 3/08 3/08, 3/09 3/08, 3/09
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Islands
3/07 3/07 3/08 3/08, 3/09 3/09 3/09 3/09

Expands
3/08 3/08 3/09

Comes back
3/09 3/09

Ok if not stressed

Ok for age

Co-regulate
Engage Circles Flow Symbolic Logical Multicausal

Grey area
Reflective

Relationships - Caregiver Profiles:

Not yet able to support Just starting to support Islands of support Moderately effective in supporting 50% Becoming consistent in ability to support Effective except when stressed Very Effective in supporting

Comforting the child Finding appropriate level of stimulation Pleasurably engages the child Reads childs emotional signals

Responds to childs emotional signals

Tends to encourage the child
]

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Relationships - Caregiver Profiles: first grade teacher, aide

Not yet able to support Just starting to support Islands of support Moderately effective in supporting 50% Becoming consistent in ability to support
mellow

Effective except when stressed

Very Effective in supporting

Comforting the child Finding appropriate level of stimulation Pleasurably engages the child Reads childs emotional signals
directive

Not fuzzy, but not reactive directive unflappable

Persistent attempts to engage him Can predict when he will become upset

Sees when he is upset

Responds to childs emotional signals

Tends to encourage the child

Unsure what to do

Interested in the flow of activity, not interaction

directive

Wants him regulated so he can learn (not interact per se)

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Relationships - Caregiver Profiles: second grade teacher, resource teacher, aide

Not yet able to support Just starting to support Islands of support Moderately effective in supporting 50% Becoming consistent in ability to support
Kind and clear mellow

Effective except when stressed

Really there for him, can help him settle Calm and positive, able to flexibly shift level of stimulation

Very Effective in supporting

Comforting the child Finding appropriate level of stimulation Pleasurably engages the child Reads childs emotional signals Responds to childs emotional signals Tends to encourage the child
Still unsure what to do directive directive Pretty good with him

Learning to engage

Some nice non-verbal flow Naturally reads his cues

Predict when he is upset

Tries hard to do this in the moment

Interested in the flow of interaction

Naturally responds

Still directive

Strong desire to see him regulated and engaged

Regulated for interaction; coaches aides, staff

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Medications Approved by the FDA for Marketing for the Treatment of Autism
Risperdal

- 10/06 - Irritability Abilify - 11/09 Irritability

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Thanks and Have a Good Day!

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Ok, theres more to it

Are medications a good thing? Medical Ethics FDA Evidence Based Medicine Informed Consent Family How Doctors Think Medications and medication options

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Its complex
People like things simple and practical This is not simple But if you follow along, it can be quite helpful and practical.

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Good Medicine
Good = it might help (help what?) beneficence Good = it wont cause bad side effects Do No Harm non-maleficence

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4 Main Principles of Medical Ethics*

doing good (Evidence Based Medicine) 2. Non-maleficence risk vs. benefit (Do No Harm) 3. Autonomy informed consent without deception 4. Justice allocation of resources, laws (avoiding aversive practices)
1. Beneficence
*Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 3rd ed. New York, Oxford: Oxford University Press, 1989.

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History of Trying to do Good

Food and Drug Act of 1906 safe medicines, not diet pills from tapeworm eggs Flexner Report on Medical Education 1910 medical care has risks and so medical education requires standards

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The FDA
Approves medication for marketing for specific symptoms of specific conditions Allows doctors to use medications for whatever they think is appropriate

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FDA Approval of a Medicine for Marketing

Requires studies showing it works for some symptoms of some condition Safety studies now for kids too! Difficult process Expensive process

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Its Especially Hard to Do Studies On Medications in Kids with ASDs

Kids are hard to find Kids have multiple diagnoses Kids with Autism are a very mixed group

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New approaches:

CAPTN
Child & Adolescent Psychiatry Trials Network
NIH / Duke Efficiency Studies Pharmacogenetics Results pending

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The upshot, for the moment

Companies seek FDA approval is for BIG MARKETS Most psychiatric medication for kids is experimental

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Doctors Need:
To

know a lot Respect for trouble Steady care Judgment & Experience

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Clinical Judgment & Experience with

the condition the medications other neurobehavioral and medical conditions side effects & drug interactions the terrible things

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Doctors Experience
Often limited In my experience = seen one In a series = seen two

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Terrible Things
Morbidity severe side effects (e.g. hepatic failure, NMS, TD, etc. etc.) Mortality

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Avoiding Trouble
Good care: follow up, AIMS, labs, etc. Laws governing medication Report medication problems to the FDA Talk to colleagues Informed consent: family choice

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Family Choice

For lifelong challenges Severe symptoms and impact Families must know their options Family circumstances and values are preeminent Hope is essential - unfounded hope is cruel Family choice is the heart informed consent

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Diagnosis Target Symptoms Treatment Protocol Alternative Treatments Results of No Treatment Side Effects FDA Labeling: experimental Consent & Assent Comments, Questions & Concerns: track closely

INFORMED CONSENT IS A PROCESS

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So why use meds?

Can

help, sometimes dramatically Duty to Inform

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Good information is part of good medical care

Could

help, and perhaps avoid harm Standard of care Practice guidelines Evidence Based Medicine
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Evidenced Based Medicine

Sackett, et. al. British Medical Journal 1996;312:71-72 (13 January) the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.

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Meaning what?
integrating clinical expertise with systematic studies consideration of clinically relevant research and respect for the individuals predicament, rights, and preferences

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Misuse of Evidence Based Medicine

cutters no research Vested Interests only our research counts Convinced Clinicians my experience is what matters
Cost

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Gold Standard Evidence

Double

Blind Placebo (or wait list) Controlled Prospective Randomized Multiple Subjects

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vs. Medicine Today:

Grave

conditions cannot wait We work with the data we have Heterogeneity of populations Extrapolating from other disorders (OCD), other populations (adults)

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And People are Human

Narrow

thinking Emotional reasoning Placebo effects References: How Doctors Think Groopman; Science and Fiction in Autism Schreibman; Lies, Damn Lies, and Science Seethaler
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So EBM requires:
Current

best evidence Clinical expertise & judgment

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Evidence Changes Over Time

Half

changes every 5 years 50% is wrong We dont which half

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 Find

one you can work with Keep the doctor informed about what is happening with meds and therapy Dont overwhelm with data Doctors can be confused (biomedical) Respectfully offer resources Good doctor consult other doctors
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 Competence:

APBN Board

Certified Ethics: AACAP = try their best

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The Role of Medication

Overview Progress? A Good Enough Program A General Approach to Medication Gridding the Problem

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1989 Magda Campbell: haloperidol helps social learning; others: methylphenidate causes side effects without benefit. 1990s - 2006: treating target symptoms, based on responses in other conditions to medications; lots of use of neuroleptics for aggression, etc. 2004 Black Box warning for SSRIs in kids 2006 Risperdal Early 2009 Celexa not working for OCD in ASD Late 2009 Abilify 2010 Cochrane report on SSRIs and autism

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Most people consider meds because they feel stuck, maybe desperate Emergencies: aggression, depression, others? Lack of progress

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What do we want for our children? The usual wish: a meaningful life
(socially, emotionally, maybe cognitively)

Requires a plan, and medication alone is not a plan.

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self regulation, sensory, and motor function trusting, supportive relationships communication, maybe language cognition & learning living and life skills: home, school, work compliance with important rules

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Are we asking too much of a child? Of a family? Of a school?

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The Central Question

Are you trying to improve an appropriate situation or make up for a bad one?

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Will they change my childs brain and fix it? Could they injure my child? What should I expect?

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To avoid losing time while pulling the program together To do as much as possible Awakenings are we trying for a miracle?

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 Cant

guarantee results If no emergency, theres time When parents disagree Side effects Treatment teams all about the meds

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 Complete

workup a must: consider (24 hour) EEG, labs, etc.

along with complete history, physical, time with the child and family, and collateral information from 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 work better

Grid

possible treatments and fill in likely +s & -s, in a flexible decision matrix

and prioritize target symptoms and

Availability - doctor MUST stay in touch with family and school

GOLDEN RULE: think carefully before rapid, large changes in dose or before changing more thing than one thing at a time.
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Gridding Target Symptoms

Target symptoms Prioritizing Symptoms Core Symptoms

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Name Your Symptoms

Activity, impulsivity Anger Attention Anxiety, specific fears Cognition Depression GI Distress Mood

instability, irritability, aggression Motor Planning O/C, rigidity Perseverati ve Pain Reciprocal

interaction Seizures Sensory Sensitivity & Processing Sleep Tics Others??

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O/C, rigidity Perseverative

Mood Instability aggression

Depression

Stimulants

+/-

+/-

+/-

+/-

+?

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

SSRIs Neuroleptics

+?

-?

+/+

-/+ -/+

+? +?

-/+ ++? -

+? +?

+? ++?? +? +

-/+ +

AEDs Steroids Central Alpha Agonists

+? -? +?

-/+ -? +?

+ +? +?

/+? +? -/+

+? -/+ +/-

++? -? 1/+?

-? +? -/+?

+? -? +?

+? ++? +?

+? -? +?

+ ? + ? + ?

+/-? +

Etc
LIST OTHER TREATMENTS!

Comments

Reciprocal interaction

Sensory Sensitivity

Cognition

Attention

Motor Planning

Anxiety

Activity

Targets

Sleep

Etc

Tics

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Core Symptoms?
Relating Communicating Healthy development: connected, regulated emotions that breathe life into adaptive thinking and planning

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 Support
Widen Treat

regulation and co-regulation by

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

tolerance of emotions so

the person is less likely to become overwhelmed.

co-occurring conditions,

e.g., depression.

Might

promote abstract reasoning and thinking.

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The Bottom Line:

medication probably does not treat core symptoms directly might make some target symptoms or co-occurring conditions better creating more affective availability so that we can make progress if you can avoid significant side effects.

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Specific Psychotropic Medications

Try to always know the brand and generic names of medications Rxlist.com is often helpful The following list and the information provided is not comprehensive; please talk with your own health care provider for further information

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Stimulants

Methylphenidate: Ritalin, Concerta, Metadate, Methylin, Focalin Dextroamphetamine: Adderall, mixed salts, Vyvanse Slightly different mechanisms. Similar possible side effects: appetite, sleep, withdrawal, depressed mood, unstable mood, tics, obsessiveness, etc. Drug diversion vs. drug abuse risk ADHD and ASD Often makes a good plan workable.
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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. Black box warning about suicidal thinking vs. lower rates of actual suicide in people treated with SSRIs

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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 for symptoms of psychosis. Helping aggression, mood stability, and miracles? As well as tics, and adjunct for depression, perseveration, etc.? Side effects can include weight, lipid, and sugar issues, as well as seizures, fevers (NMS) and new abnormal movements (TD), stroke (elderly), cardiac Should we always consider neuroleptics?

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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

109

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, weight gain, sedation, rash Trileptal (oxycarbezine) 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 rash Topamax (topiramate) adjunct, may cause weight loss, loss of expressive language, usually need to go slow. Neurontin (gabapentin) Does it work at all? Does it harm at all? Does help pain syndromes. Lyrica (pregabalin) for pain in fibromyalgia, partial seizures Zarontin (ethosuccimide) for partial/ absence seizures; liver issues
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Steroids

LKS variant theory epileptic aphasia 24 hr EEGs Regression at a young age Cell membrane stabilization in inflammation So many side effects: cushinoid, moon face, hump, central obesity, peripheral wasting, immune compromise, skin striations, mood instability including depression and hypomania Pulsed dosing regimens

112

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

113

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, seiaure risk Rozerem (ramelteon) melatonin agonist SNRIs Effexor (venlafaxine), Cymbalta (duloxetine), Remeron (mirtazepine), Serzone (nefazedone), Pristique (desvenlafaxine). Deseryl (trazodone) antidepressant often used for sleep; cognitive side effects, priapism Buspar (an azaspirone) mild, serotonergic cross reactions
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More Others
Lithium great mood stabilizer; antisuicidal; bipolar-ASD connection; levels, thyroid, kidney function 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

115

Meds that I often avoid

Paxil (paroxetine), Effexor (venlafaxine), Cymbalta (duloxetine) - withdrawal Tegretol (carbemazepine) hard to make it work Combo Depakote and Lamictal Tricyclics Tofranil (imipramine), Norpramin (desipramine), Pamelor (nortriptyline); and, esp. good for typical OCD, Anafranil (clomipramine). Cardiac and 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 drug-drug interactions

116

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

117

O/C, rigidity Perseverative

Mood Instability aggression

Depression

Stimulants

+/-

+/-

+/-

+/-

+?

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

SSRIs Neuroleptics

+?

-?

+/+

-/+ -/+

+? +?

-/+ ++? -

+? +?

+? ++?? +? +

-/+ +

AEDs Steroids Central Alpha Agonists

+? -? +?

-/+ -? +?

+ +? +?

/+? +? -/+

+? -/+ +/-

++? -? 1/+?

-? +? -/+?

+? -? +?

+? ++? +?

+? -? +?

+ ? + ? + ?

+/-? +

Etc
LIST OTHER TREATMENTS!

Comments

Reciprocal interaction

Sensory Sensitivity

Cognition

Attention

Motor Planning

Anxiety

Activity

Targets

Sleep

Etc

Tics

118

Getting back to the tree

119

Receptive Communicatio n

Expressive Communicatio n

Other medical

Visual Spatial

Sensory Processing

Motor tone and motor Planning

Stimulants

-/+?

-/+?

-/+?

-/+?

-/+?

-/+?

-/+?

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

SSRIs Neuroleptics

AEDs Steroids Central Alpha Agonists

Etc
LIST OTHER TREATMENTS!

Comments

Praxis

Targets

Etc

120

Co-regulation

Engagement

Number 10?

Multicausal

Stimulants

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

SSRIs Neuroleptics

AEDs Steroids Central Alpha Agonists

Etc
LIST OTHER TREATMENTS!

Comments

Reflective

Symbolic

Nuance

Targets

Logical

Circles

Etc

Flow

121

Ethical rules

Arithmetic .

Trade skills

Swimming.

Reading..

Writing

Stimulants

Wt Ht tics Wt, Ht Sz

SSRIs

Neuroleptics

Wt. Sz TD NMS
Mult. SE Mult SE Sleep BP

AEDs Steroids Central Alpha Agonists Etc LIST OTHER TREATMENTS!

Comments

Targets

Etc

122

Etc
Targets Comforting the child Finding an appropriate level of stimulation Pleasurable engaging the child Reading the childs emotional signals Responding to the childs emotional signals Encouraging the childs development

AEDs

SSRIs

Steroids

Stimulants

Neuroleptics

Central Alpha Agonists

LIST OTHER TREATMENTS!

Etc Wt Ht tics
Mult SE Mult. SE Sleep BP Wt, Ht Sz Wt. Sz TD NMS Comments

123

124

Abnormal Involuntary Movement Scale (AIMS)

125

Look at the whole picture, and reflect Be careful with meds Engage the Child

Your Experiences?

126

Never give up, never surrender!

- Captain Peter Quincy Taggart
Commander, NSEA Protector