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Psychiatry Treatment in Individuals with Developmental Delays Philip L. Baese, MD Assistant Clinical Professor of Psychiatry University of Utah, Department of Psychiatry Neurobehavior/HOME Program Background Issues Under-recognized/under-treated psychiatric problems Why? Doesn’t fit neatly into descriptive categories of DSM IV Behaviors themselves become the focus of treatment, without understanding underlying etiology Complicating medical problems Complex psychosocial environments with variable amounts/consistency of collateral information from observers Increased risk of psychiatric illness in those with MR around 2-3X that of general population Prevalence estimates of 30-70% of those with MR have an additional psychiatric diagnosis Typical Diagnostic Categories Mood Disorders Depression Bipolar Disorder Anxiety Disorders Generalized Anxiety Panic Disorder Post-traumatic Stress Disorder Obsessive Compulsive Disorder Autism Spectrum Disorders (ASD)/Pervasive Developmental Disorders (PDD) Asperger’s Autism Typical Diagnostic Categories Disruptive Behavior Disorders Oppositional Defiant Disorder Conduct Disorder Attention Deficit/Hyperactivity Disorder Tic/Stereotypic Movement Disorders Tourette’s Syndrome Psychotic Disorders Schizophrenia General Aspects of Mental Retardation Significantly subaverage intellectual functioning (intelligence quotient below the 70-75 range measured on standardized test) Significantly impaired adaptive functioning Onset prior to age 18 85% fall in the mild-moderate range General Aspects of Mental Retardation 35% an identifiable genetic cause is found (such as Fragile X Syndrome, Down’s Syndrome, etc.) <10% a malformation syndrome of unknown origin is found 33% external/pre/peri/post natal factors can be identified (infections, trauma, toxins, hypoxia, drug exposure, prematurity) Challenging Behaviors: The Big Four 1. Self-injurious Behavior 2. Physical Aggression towards others 3. Destruction of Property 4. Inappropriate Sexual Behaviors Broad Etiologic Categories 1. Medical Conditions Genetic disorders with identifiable “behavior” phenotypes Prader-Willi Syndrome Down’s Syndrome William’s Syndrome FG Syndrome Fragile X Syndrome Smith-Magenis Syndrome Broad Etiologic Categories 1. Medical Conditions Epilepsy Partial complex Generalized absence Endocrinologic/Metabolic Disorders Thyroid disease Diabetes Wilson’s Disease (copper metabolism) Toxin Effects Lead poisoning Fetal alcohol (or other drug) effects Sleep Disorders Obstructive sleep apnea (central and peripheral) Periodic limb movement disorder narcolepsy Broad Etiologic Categories 1. Medical Conditions Gastrointestinal Conditions Constipation Reflux Infections/Pain Chronic otitis, dental abscess, sinusitis Toxin Effects Lead poisoning Fetal alcohol (or other drug) effects Sleep Disorders Obstructive sleep apnea (central and peripheral) Periodic limb movement disorder Narcolepsy Broad Etiologic Categories 2. Psychiatric Disorders 3. Adaptive Dysfunction (mismatch between individual and environment) COMMUNICATION limitations Parental temperament Level of supervision/support Failure to recognize/manage major life changes (puberty, graduation from school system, move out of family of origin’s home, loss) Treatment Approach Assess each of the broad categories listed above and exclude medical causes first Functional Analysis of Behavior Biopsychosocial formulation Family history is important Early developmental history is important Psychosocial history is important (assess home life, school life, and peer relationships) Treatment Approach Formulate a working hypothesis Consider medication side-effects or adverseeffects as a primary cause Consider a worsening or undetected medical cause (e.g., worsening seizure control or sleep apnea) If underlying psychiatric illness suspected, consider psychopharmacologic trial General Rules for Psychopharmacology in DD Population 1. All bets are off – dealing with ‘fragile’ brains that do not always respond as expected 2. Start low/go slow – begin at low dosages (1/3-1/2 of usual dose in non-DD population 3. Be methodical – make one change at a time and wait adequate amount of time for a response; quantify response as much as possible (e.g., serial rating scales) 4. Follow-up frequently – reassess on a frequent/ongoing basis for adverse effects General Rules for Psychopharmacology in the DD Population Additional Considerations Compliance with oral medications transdermal patch Intramuscular injection Liquid/rapidly dissolving preparations Need for invasive monitoring for side effects Drug levels Liver and bone marrow function EKG (QTc interval) Interactions with other medications, including over-the-counter, herbals, etc. Effects of multiple time/day dosing on providers/school system Risk of ingestion or overdose Commonly Used Medications Depression/Anxiety SSRI = selective serotonin reuptake inhibitor Fluoxetine = Prozac (20 – 60 mg) Sertraline = Zoloft (50 – 200 mg) Paroxetine = Paxil (20 – 60 mg) Fluvoxamine = Luvox (50 -200 mg) Citalopram = Celexa (20 – 60 mg) Escitalopram = Lexapro (5 – 20 mg) Commonly Used Medications Depression/Anxiety Benzodiazepines Clonazepam = Klonopin (0.25 – 6 mg) Diazepam = Valium (5 – 20 mg) Lorazepam = Ativan (0.5 – 8 mg) Other Buspirone = Buspar (5 – 30 mg) MMA = mixed mechanism antidepressants Venlafaxine = Effexor (50 – 300 mg) Bupropion = Wellbutrin (75 – 300 mg)* Duloxetine = Cymbalta (20 – 60 mg) *lowers seizure threshold/contraindicated with epilepsy Expected Response/Adverse Effects SSRIs: takes 3-6 weeks or more for anxiety for potential benefit MMAs: takes 2-4 weeks for potential benefit Adverse Effects/Side Effects that are common include diarrhea, GI upset, sexual dysfunction, sleep problems, sedation, paradoxic agitation or “activation” of manic symptoms Benzodiazepines: work within 1-2 hours Adverse Effects/Side Effects include disinhibition, agitation, sedation Commonly Used Medications Mood Dysregulation (Bipolar): so-called “mood stabilizers” Non-AEDs Lithium = Eskalith (150 – 1200 mg) [blood level 0.8-1.2) AEDs (antiepileptic drugs) Divalproate = Depakote (125 – 1500 mg) [blood level 80-100] Carbamazepine = Tegretol (200 – 800 mg) [blood level 8-10] Oxcarbazepine = Trileptal (300 – 1200 mg) Lamotragine = Lamictal (50 – 400 mg) Gabapentin = Neurontin (300 – 2000 mg) Expected Response/Adverse Effects Lithium: can work within 7-10 days or sooner; therapeutic blood level is key Adverse Effects include upset stomach, diarrhea, excessive urination, cognitive dulling, weight gain, acne, tremor Toxic Effects (overdose) are life threatening: gait problems, confusion, and coma Therapeutic blood level is key Expected Response/Adverse Effects AEDs: can work within days for stabilizing mood symptoms Often need to be tapered up and down slowly (shouldn’t be stopped abruptly due to risk of rebound siezure) Some require therapeutic blood level for optimal efficacy Some require monitoring of liver function and bone marrow function (carbamezepine/divalproate) Common side effects include weight gain, cognitive dulling, sedation, tremor Blood monitoring can be difficult in DDMR population Some more effective than others (divalproate > carbamezepine > gabapentin) Lamotragine is promising (antidepressant effects), but must be tapered upward slowly due to risk of life threatening rash (Steven Johnson Syndrome) Commonly Used Medications Agitation/Mood Dysregulation/Overarousal “Atypical” Antipsychotics (block dopamine receptors and serotonin receptors) Risperidone = Risperdal (0.5 – 8 mg) Olanzapine = Zyprexa (5 – 30 mg) Quetiapine = Seroquel (50 – 800 mg) Ziprasidone = Geodon (40 – 120 mg) Arapiprazole = Abilify (5 – 20 mg) Expected Response/Adverse Effects Atypical Antipsychotics Work within hours (calming/sedating effects) to days (mood stabilizing effects) Common side effects include weight gain (except ziprasidone/aripiprazole), long-term metabolic changes and insulin resistance (can lead to diabetes), sedation Changes in cardiac rhythm can occur (potentially lethal, such as prolonged QTc interval) Less risk of EPS (extrapyramidal symptoms), but can occur = drug induced Parkinsonism (cogwheel rigidity, tremor, wide based gait, drooling); dyskinesias Serious long-term effects include tardive dyskinesia = involuntary movements that are not reversible, even with drug discontinuation Life threatening reaction = NMS (neuroleptic malignant syndrome) characterized by stiffness, vital sign instability, fever, delerium Commonly Used Medications Disruptive Behavior Disorders (like AD/HD) Stimulants* Methylphenidate = Ritalin (multiple long-acting formulations) Dextroamphetamine = Dexedrine Mixed amphetamine salts = Adderall *dosed by weight: methylphenidate least potent with average dose of 1 mg/kg/day Non-stimulants Atomoxetine = Strattera (18 – 80 mg) Clonidine = Catapress (0.025 – 0.4 mg) Guanfacine = Tenex (0.5 – 2 mg) Expected Response/Adverse Effects Stimulants work in 30 minutes; short acting preparations are dosed multiple times per day Stimulants improve attention/focus and decrease impulsivity Common side effects include appetite suppression, upset stomach, tics (reversible), tachycardia Need to monitor growth/weight in children and blood pressure Non-stimulant (atomoxetine) takes 2 weeks for effects Non-stimulant (clonidine) causes a non-specific decrease in hyperactivity and can be sedating; need to monitor blood pressure Sleep Medications Sleep Medications: these are many and varied in their effectiveness Sleep problems are complex issues and may be secondary effects of a psychiatric problem or may be primary sleep disorders Remember, tiredness does not equate to the quality/restfulness/restorative nature of sleep Many medications cause sedation, but do not improve sleep quality (and some actually interfere) Example: Benzodiazepines suppress REM sleep Commonly Used Medications Trazodone = Desyrel (25 – 200 mg) Melatonin (over the counter) (1 – 6 mg_ Diphenhydramine = Benedryl (25 – 100 mg) Zolpidem = Ambien (5 – 20 mg) Zaleplon = Sonata (5 – 20 mg) Eszopiclone = Lunesta (1 – 3 mg) Ramelteon = Rozerem (8 mg) Expected Response/Adverse Effects Most sleep aids produce sedation within 1 hour of taking them Some are designed only for initial insomnia and sedating effects wear off by 3-4 hours Some are designed for middle insomnia and continue to cause sedation up to 8 hours after taking Continuous use can cause attenuation of sedating effect over time Can be used for months at a time, but should prompt ongoing evaluation for underlying causes that are amenable to nonmedication treatment (like sleep hygiene). Primary sleep disorders (apnea) need treatment with CPAP (continuous positive airway pressure to prevent long-term complications (cardiopulmonary) Treatment Approach to Developmentally Delayed Individuals Assessment (takes time) Current symptoms/behaviors of concern: severity, duration, setting, triggers Psychiatric review of symtoms including adaptive functioning, self-care, communication, social/school functioning Details of previous psychiatric treatment including previous medications, response, side effects Treatment Approach to Developmentally Delayed Individuals Assessment (cont.) Parent/Caregiver attitudes and long-term plans Review of prior psychological/cognitive testing Past/Present educational/work and habilitative functioning Work programs, living situation, habilitative supports Multidisciplinary/Team Approach Due to complexity of caring for those with Developmental Disabilities, multiple care providers are usually involved Results in complex, interacting systems where communication is critical (both within and outside of clinic setting) Communication with outside caretakers/teachers is often indirect (parent reports/letters) Often, direct communication is neccesary/useful Constraints placed on patient confidentially or parental preference can be barriers Multidisciplinary/Team Approach The Players Parents/Care Providers Child/Adolescent/Adult Psychiatrist Behavior Specialist Case Manager Medical Assistants Primary Care Physician Geneticist Specialty Consultants (Pulmonologist/Neurologist/Rehabilitation) Therapists (family, individual) Special Education Teachers Adaptive Therapists (speech/physical/occupational) Human services (Utah = DSPD and/or DCFS) UNI H.O.M.E. Program (Healthy Options Medical Excellence) UNI HOME Clinic Behavioral/Psychiatric Services •Psychiatrist •Therapist •Behavior Specialist •Group Therapists Case Management •Liaison with school (teachers) •Liaison with DSPD •Liaison with residential providers/families •Facilitate communication •Treatment planning meetings •IEP reviews •Letters •Specialist care coordination •Advocacy Primary Care •Family Physician (focus on preventive care) •Nurse Practitioners (physician extenders) •Nutritionist •Access to Habilitative Services (speech, physical, occupational) Medical/School System Interface Barriers to Communication Legal – HIPPA (Health Information Portability and Protection Act): requires parental/guardian permission to disclose protected medical information Geographic – school and clinic staff in different locations Time – teachers and caregivers are busy (difficult to connect) Medical/School System Interface Unhelpful Stances The demanding/entitled physician, teacher, or parent The disparaging physician, teacher, or parent The undermining physician, teacher, or parent The overwhelmed physician, teacher, or parent The indifferent physician, teacher, or parent Medical/School System Interface Constructive Stances Open communication (invite parent/care providers/teachers into dialogue Capitalize on natural settings within each culture (IEP meetings at school or treatment planning meetings at a clinic) Discuss expectations ahead of time to avoid disappointment Review interventions regularly Utilize technology/variety of communication forms (letters, e-mail, video tape (with consent), phone, rating scales) Be flexible Medical/School System Interface Practical Advice for Special Education Teachers Be open to observing/documenting behaviors in the classroom in the context of ongoing treatment Allow yourself to be a blinded observer and complete requested rating scales Communicate concerns about effects of medication (side effects such as sedation or agitation) to parents Don’t tolerate the sedated/sleeping child who isn’t disruptive Guide clinicians/parents in their advocacy efforts Be over vigilant with sensitive psychiatric or mental health information Medical/School System Interface Practical Advice for Special Education Teachers You know the child’s educational style/behavior in the classroom better than anyone else Communicate observations of social and learning interactions impartially, but accurately (avoid using extreme descriptions which can be misleading) Utilize existing resources within the school system (school psychologist) Advocate within your school for the resources you need to do your job