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Things to consider in the use of

medication for persons with


developmental and learning
disorders
Assistant Clinical Professor, Dept of
Psychiatry, University of California
at San Diego School of Medicine

Faculty, Interdisciplinary Council


on Developmental and Learning
Disorders
ICDL Faculty – minimal - review of
clinical write ups, travel and room
for summer institute
NIMH/ Duke University – minimal –
administrative time for
pharmacogenetic research
 Quick history: Magda Campbell: haloperidol
helps social learning; others: methylphenidate
causes side effects without benefit.
 Today: we try to treat target symptoms,
carefully, based on responses in other
conditions to medications.
 Takes time to assess, and re-assess.
 Marketing, and side effects, and efficacy
studies.
 Efficiency study: CAPTN (Duke: John March, el al
– I’m an et al…).
Most people consider meds because
they feel stuck, maybe desperate
Emergencies: aggression, depression,
others?
Lack of progress: in what areas?
What do we want for he child?
What the meaning of the disability is
to the family and to your child?
Goal: a meaningful life socially,
emotionally, and cognitively.
Requires a plan, and medication
alone is not a plan.
regulatory issues/ motor and sensory
areas addressed
engagement and reciprocity
language/ communication
cognition/ learning
daily living skills followed by broader
and broader areas of life skills, from
school and playground to vocational
skills.
Mirror neuron systems
Joint attention and relationship-based
intervention
GxE: genetics and environment
 Pharmacogenetics
And then there is always the math…
Are we asking too much of the child?
Of the family?
Of the school?
Low Support - Low Low Support - High
Expectation Expectation
(neglect…) (‘Just do it…’)

High Support - Low High Support - High


Expectation Expectation
(walking on eggshells, more (respectful coaching)
and more constricted…)
Isthe program adequate?
Will they change the child’s brain and
actually fix it?
Will they injure the child?
What should I expect?
Losing time while pulling the program
together
Doing as much as possible
Awakenings – should we go for a
miracle?
We do not know enough to say ‘you
really should medicate’
If there is no emergency, you have
more time to think about it
When parents differ, if makes for
more thoughtful planning
 
 Are you trying to save a placement or make
up for a bad one?
 Are meds a last resort or is it unethical to
withhold them?
 Complete workup a must: consider EEG,
labs, etc. along with complete history,
physical, MSE, and collateral information.
 Availability - doctor MUST stay in touch with
family and school
 Rapid, large, or multiple changes are often
problematic
 Grid target symptoms vs. possible meds and
fill in possible +’s &-’s
 Support regulation and co-regulation by
treating symptoms that get in the way,
e.g., impulsivity, inattention, anxiety, rigid
thinking, perseveration.
 Widen tolerance of affective experience so
the person is less likely to become
overwhelmed.
 Treat
co-morbid conditions, e.g.,
depression.
 Possibly: allow for or promote improved
ability for abstract reasoning and thinking.
 Easy for the treatment team to react and
overuse medications
 Side effects often create significant
difficulties, e.g., behavioral activation
(SSRIs), increased perseveration
(stimulants), sedation (some
anticonvulsants, others).
 Team treatment often becomes ‘all about
the medication’, ignoring engagement, other
factors.
 Bottom line: medication most probably do
not treat core symptoms, but might create
more affective availability, if you can avoid
significant side effects.
 Find
a doctor you like and feel you can
work with
 Keep the doctor in the loop
 Don’t overwhelm the doctor with data
 Think
carefully before rapid, large
changes in dose or before changing
more thing than one thing at a time.
 Respectfullyoffer resources – don’t expect
your doctor will read a book for you, but do
expect your doctor is interested in other
opinions from other doctors
Look for Basic Competence:
APBNBoard Certified Child and
Adolescent Psychiatrists were
checked for competence in assessing
autism, and for use of collateral
information from family, school, and
other professionals.
Look for Honesty: AACAP = a
promise to be ethical and do their
best
Helping parents determine when
medication may be worth considering
Helping families navigate well to
utilize their doctors and other
providers
Helping families orchestrate the
whole set of interventions into a
coherent and manageable plan
Good Luck!
 

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