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Prescribing For Young People With Learning Disability

Prescribing For Young People With Learning Disability. Food For Thought. Ethical Issues, Holistic Assessment and Clinical Practice. Food For Thought. ‘We forfeit three-quarters of ourselves to be like other people’ Arthur Schopenaur

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Prescribing For Young People With Learning Disability

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  1. Prescribing For Young People With Learning Disability

  2. Food For Thought 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. Pathophysiology in MLD

  6. 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

  7. 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

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

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

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

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

  12. 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

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

  14. ACTING OUT #1

  15. ACTING OUT #2

  16. ACTING OUT #3

  17. 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

  18. 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

  19. 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

  20. 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’

  21. 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

  22. 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)

  23. Useful Websites #2 • http://www.merseycare.nhs.uk/Library/What_we_do/Clinical_Services/Pharmacy/LearningDisabilities-Finalv3.pdf ‘Merseyside Clinical Guidelines’

  24. Thank You For Listening

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