The Role of Medication and Other Biological Approaches in Infants and Early Child Mental Health aka Psychiatric

Medications and Young Children

Josh Feder MD We Cant Wait September 28, 2013

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

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 early intervention Circlestretch community resource Cherry Crisp media company

Specific Gratitude
Jeff, Jeff, Jeff: It s always been about the Jeff ECMHSL group Local Colleagues: DIR, Rady/ UCSD, etc., etc.

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.

Outline
(Partial Bait & Switch)

Evidence Based Medicine/ Practice The bio-psychosocial model & DIR Medicine and other biological approaches

Dont sweat the details - this talk will be posted on

Where to start? Its a big universe

scientific 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 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.

Striving for 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)

the three core principles of Evidence Based Practice

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

Minimum Meme = baby+caregiver

Similarly

We can only understand a child in context

When we think about helping a child function better

We need to think about supporting caregivers

Its Complicated: Bio - Psycho - Social

Biological Psychological Social George Engel: cardiac care Carl Whittaker: the buffy coat

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Its Complicated: Bio - Psycho - Social

Covers a broadening range of possible influences Gets you thinking about all the factors involved Brainstorm with BPS as your guide

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Example: Babys not sleeping

BPS/SPB
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 is down 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

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Its Always So Complicated We need an Organizing Philosophy

Using DIR as an Organizing Philosophy for a BPS Developmental Approach

Broad whole child, supports family Welcoming all about building love Enriching closeness can bring progress

DIR in a nutshell
Stanley 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 about connecting, and making time with others for support and help

Developmental
three 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

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 be regulated (attention, impulsivity, overaroused/hypervigilant, low arousal, seizures etc.)?

Engagement Truly Connected Affective connection drives internal motivation for

communicating and learning if you dont care, you dont 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.?)

 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 that medication might address to help the child (rigid or negative thinking, irritability, etc.?)

Reciprocity - Flow of Interaction

Assessment
Observations: 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

DIR Summary of Assessment

Developmental: stability of capacity for Regulation- 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 development What does the support system look like?

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, reflective opportunities, reflective institutions

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, reflective opportunities, reflective institutions

Medications and other biological approaches

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 without insurance, 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 still arent going well, then we should consider medications

 Complete workup: consider (24 hour) EEG, labs, etc. along with complete history, physical, time with the child and family, and collateral information

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
Build the care plan: and once that is in place, if it appears medicaiton may help then 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 thing than one thing at a time.
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from school, therapists, etc.

better

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??

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Infants and Young Children are Different

Infants and Young Children are Different

Liver: enzymes (more of some, less of others), liver to body ratio Plasma: 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 by 2 (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 not Skin, eye membrane permeability is increased (think toxins)

Look it up

History of psychotropic use in Infants and Young Children:

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

Evidence Based Practice and psychotropic use in Infants and Young Children:
Research is limited, but may be supportive. We borrow from adult world but this is not necessarily appropriate to do Clinical experience typically suggests we start low, go slow, and try not 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 trying to have a child conform to a harsh regime at home or school) or shunning them when we feel they might be very helpful or even vitally important (e.g. clear severe bipolar). Informed consent Parents should almost always be the actual decision makers. Ethical, rational approaches often require lots of time to talk and think things through together in a reflective and ongoing process throughout the course of care

 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 of emotions so the person is less likely to become overwhelmed, withdraw; more able to maintain engagement failure of natural positive exploratory attitude depression, anxiety, etc. Better able to repair and build resilience over time. Reciprocity: Treat co-occurring conditions/ symptoms, e.g., negative thinking, irritability; mood stability, rigid thinking, perseveration. Might promote abstract reasoning and thinking.
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O/C, rigidity Perseverative

Mood Instability aggression

Depression

Reciprocal interaction

Stimulants

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+/-

+/-

+/-

+?

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

SSRIs Neuroleptics

+?

-?

+/+

-/+ -/+

+? +?

-/+ ++? -

+? +?

+? ++?? +? +

-/+ +

AEDs Central Alpha Agonists Etc LIST OTHER TREATMENTS!

+? +?

-/+ +?

+ +?

/+? -/+

+? +/-

++? 1/+?

-? -/+?

+? +?

+? +?

+? +?

+? +?

+/+

Comments

Sensory Sensitivity

Cognition

Attention

Motor Planning

Activity

Anxiety

Targets

Sleep

Etc

Tics

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.
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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. 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.

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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.? 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, blood counts, 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 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

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

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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
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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 work themselves 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 about supplements, 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.

Common Household 'Potions'

Breast milk: mother of them all - from preventing illness through antibodies to improving cognitive outcomes and reducing rates of later conduct disorder Hydration and sports drinks (fructose/ electrolytes). Chicken soup for colds Gatorade for rehydration - fructose and electrolytes Tea and honey (and whiskey?) for sore throats Coffee - reduces depression in women Whiskey on gums for teething
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Various Common Supplements

Herbs: parsley for digestion and better breath Minerals: zinc: may prevent depression; chromium may help depression Omega 3 fatty acids Eicosapentaenoic Acid (EPA) and Docosahexaenoic Acid (DHA) for depression and for mood stability, as well as to protect against Tardive Dyskinesia with neuroleptics Amino acids: inositol (depression, schizophrenia); Dcycloserine (OCD); L-tryptophan (sleep) Vitamins: D3 (depression, etc.), B vitamins (relief of stress); Niacin (B3): reduces cholesterol, triglycerides. Really Bad ones: bath salts (mephedrone), THC psychosis risk, loss of hippocampal cells
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Other Available Means

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 change emotional 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.
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Summary:
Organize your thinking around Regulation, Engagement and Reciprocity, what the world can do to 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.

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