Prescribing For Young People With Learning Disability

1. Prescribing For Young People With Learning Disability Dr Don MacFarlane PhD., MB., MRCPsych, MSc., DPM Lakeview, Gransha Park, Derry

2. Ethical Issues, Holistic Assessment and Clinical Practice

3. Food For Thought ‘We forfeit three-quarters of ourselves to be like other people’ Arthur Schopenaur ‘If a man does not keep pace with his companions, perhaps it is because he hears a different drummer. Let him step to the music that he hears, however measured or far away’ Henry David Thoreau

4. Developmental Disorder • Onset during gestation, from birth or from early childhood • Deviation from the average in how the child perceives, thinks and feels • Encompasses domains of behaviour • Accompanied by distress and problems in performance

5. Ethical Issues in MLD and SLD • Seeking Consent capability of taking decisionacting voluntarily without undue persuasiongiven enough information • Good Practice patient’s welfare is first concern safety, dignity and comfort is maintained treat with dignity and respect listen to concerns and preferences be open and honest

6. Dysmorphology in MLD and SLD • Cortical invaginations or cerebromalacia • Agenesis or microcephaly • Lateral ventricle malformations • Anomalies of corpus callosum • Subgenual cingulate gyrus • Increased CSF • Cerebellar and vermalhypogenesis • Basal ganglia reduction

7. PHYSICAL EXAMINATION IN SLD • Head circumference • Height and weight • Canthal distance • Flat philtrum • Intraorbital distance • Breadth of forehead • Facial muscle movement • Clinodactly • Abnormal nails

8. SPECIALIST PRESCRIBING • Person-centred approach • Evidence-based • Care pathways (collaborative with mainstream) • Maximise independence and social inclusion • Minimise hospitalisation • Promote safeguarding • Fulfil legal and ethical requirements

9. LD Care Pathways • Psychological mental comorbidity and behaviour problems offending developmental pervasive disorders. • Physical sensory profound, multiple or complex nutrition, epilepsy

10. BEXLEY Audit Findings • 57% of clients regularly reviewed • 29% had Challenging Behaviour Risk Assessment (FACE?) • 51% had written care plan • 22% had keyworker • 32% had reasons recorded for no further assessment • 55% had blood profiles regularly recorded • 24% had diagnosis of autism; 68% had mental illness

11. Emotional Instability • Conflicts with others • Inability to cope with being thwarted • Inability to consider consequences • ‘Meltdowns’ • Confusion about differentness • Inability to visualise aims and preferences • Self-injurious behaviour

12. SWAP 200 • At the mercy of spiralling emotions • No stable image of self • Anxiety about rejection and abandonment • Need for external soothing • Elicits mirrored feelings in others • Has disregard for safety or welfare of self and others • Unawareness of others’ needs

13. Clinical Depression • Ego Threat – sadness, failure, loss of pleasure, blame, punishment, worthless • Vegetation – sleep, fatigue, appetite, libido • Arousal – energy, agitation, irritability, concentration, focus

14. Developmental Tasks • Capable v.Helpless • Adventurous v. Avoidant • Persistent v. Quitting • Affectionate v. Detached • Assertive v. Submissive • Volatile v. Calm

15. Behavioural Modelling • Self Fulfilment (Maslow) • Aspirations • Norms • Scripts • Empathy • Congruence • Goals

16. Behavioural Models • Reasoned Action (Ajzen) • Congruence (Frijda) • Dynamic Attachment (Crittenden) • Behavioural Analysis (Snyder) • Procedural Sequencing (Chaiken) • Reciprocity (Gambrill) • Mentalising (Fonagy)

17. Primary Emotions • Anger – demeaning offence against self • Anxiety – uncertain threat against self • Sadness – experience of irrevocable loss • Happiness – progress towards a goal • Pride – achievement of a goal • Love – affection for idealised other

18. Secondary Emotions • Relief • Frustration • Hostility • Disgust • Hurt • Embarassment

19. ACTING OUT #1

20. ACTING OUT #2

21. ACTING #3

22. CAVEATS WITH SSRIs • SSRIs can cause A-V defects in first trimester of pregnancy • Impotence from SSRIs can be counteracted by Periactin • Contraceptives can be impaired by modafinil • Risperidone can induce hypomania • Fluoxetine can double blood levels of mood-stabilisers • Tryptophan can cause serotonin overload • ‘Poop-out’ on fluoxetine occurs in 20% of cases

23. CAVEATS with NEUROLEPTICS • Haloperidol loses its anxiolytic effect in higher doses • Abilify can improve executive functioning • Abilify can cause suicidality due to akathisia • High blood sugars with olanzapine if relative has diabetes • Risperidone does not work above 6mg daily in adults • High prolactin levels stunt growth and delay puberty

24. CAVEATS with ANTICONVULSANTS • Suicide risk can be increased with anticonvulsants • Fortnightly checks of LFTS and serum levels of Tegretol • Children and adolescents are resistant to mood-stabilising • Children with ADHD are prone to have behavioural side-effects from mood-stabilisers • Atypical antipsychotics are just as effective

25. CAVEATS with ADHD medication • ADHD Assessment Instruments are not geared to MLD • Rebound and ‘Poop Out’ are not reasons for discontinuation • ADHD is easily mistaken for other conditions such as bipolar • Developmental charts should be regularly consulted • Bone profile and scanning should be considered • Atomoxetine and SSRI combo is to be avoided • Cardiac history and QTc should be monitored

26. CASE STUDY (MLD+ASD+ADHD+BPD) • Aged 5 – ASD (aggression, agarophobic, insomnia, hyper) > risperidone 1mg nocte> global improvement ‘a new man’ • Aged 6 – regressed > olanzapine 2.5mg nocte > mum says needs dose increased > 5mg nocte > excellent improvement • Aged 9 – regressed > risperidone 2.75mg • Aged 9 – ‘high and anxious’ > risperidone 1mg > labile, insomnia • Aged 13 - > ADHD > risperidone 1.5 mg > ‘excellent progress’

27. CASE STUDY continued • Aged 13 – BST > mood improved, less agitated, on risperidone 1.5mg + >melatonin > ‘brilliant’ > ADHD? • Aged 13 – YMRS, violent to Mum, BST continues >EEG > ADHD ‘confirmed’ > Medikinet > ‘good benefit’, ‘content’ relaxed’ • Aged 14 – Medikinet stopped due rebound effect > ‘back to normal’ • Aged 14 – ‘giddy and lively’ > atomoxetine > EMW but ‘good effect’, ‘moods improved’, ‘happier and less tearful’ • Aged 15 – giddy, echolalia, repetitive movement > BPD > valproate + risperidone + atomoxetine • Aged 15 – atomoxetine discontinued > clonidine 0.75 mg

28. Useful Websites • http://amberlist.wordpress.com ‘Prescribing for Young People’ • http://johnalstonmd.com/docs/ADD_Bipolar_RAD.pdf ‘Juvenile Bipolar Disorder’ (John Alston, Baltimore) • http://www.familyrelationsinstitute.org/include/dmm_model.htm ‘Dynamic Maturational Model’ (Patricia Crittenden, Miami)

29. Useful Websites #2 • http://www.merseycare.nhs.uk/Library/What_we_do/Clinical_Services/Pharmacy/LearningDisabilities-Finalv3.pdf ‘Merseyside Clinical Guidelines’ • http://www.rcpsych.ac.uk/pdf/FutureroleofpsychiatristsinLD%20services.pdf ‘Future Role of Psychiatrist in Learning Disability’ RCPsych • http://depts.washington.edu/dbpeds/Dysmorphology%20Training%20Manual%201-10-08%20(2).pdf‘Dysmorphology Training Manual’. • http://www.dhsspsni.gov.uk/consent-guidepart4.pdfSeeking Consent in MLD, DHSSPNI Document

30. Thank You For Listening