1. The role of polypharmacy in children with developmental disability: Art or science Natalie Silove CHW

2. Case Study Simon 13 year old Severe Autism, Intellectual disability Non verbal Normal perinatal history Autism and DD diagnosed by 3 years ABA started 30 hours a week CAM +++

3. First consult at age 8 years old Severe hyperactivity impulsivity no concentration Very obsessive water play, light flicking Lots of stereotypies Head banging rocking, Throwing, biting, hitting Vision hearing ok Recurrent episodes of vomiting, ear infections, bleeding nose, ears, over many years

4. MEDICATIONS TRIALED: Fluoxetine ( lovan) caused increased aggression/agitation/ stopped Fluvoxamine 25mg mane 50mg nocte – helpful for 18 m and then esclating aggression) Methylphenidate/dexamphetamine no improvement ceased Introduced Endep ( amitriptyline)helpful, Carbamazepine ( very helpful) ceased due to rash after adequate trial Risperidone initially helpful ceased due increased appetite and weight aripiprazole started Diazepam ceased due to tolerance

5. Current medications –Rabeprazole (Pariet ® ) one tablet nocet –Naltrexone (50mg tablet)1/2 tablet BD –Clonidine ( 100ug )1/2 tablet m, lunch and 1 nocte –Aripriprazole(10mg tablet) ½ TDS –Amitriptyline 25mgTDS NB: medical/psych/communication/sensory/OT/beha vioural/parenting/social support/referrals etc

6. Social History Simon is the oldest of two children of Australian Couple. Father in IT and Mother RN Happy marriage, no primary health or mental health problems Mother stopped work to ensure adequate intervention and support in early years and to maximise ABA, went back to work when Simon at school Changed schools four times Stopped work again when school could not cope with behaviour – tried home school, with ABA and ADHC support

7. Mother became more isolated, put on weight, sleep affected diagnosed with depression, refused medication and respite Aggression directed to mum, accepted overnight respite provided for two nights every 3-6 months, but respite would call parents and they would have to pick him because aggression Mother hospitalised for depression and suicidal behaviours – emergency services brought in to the home, constant changing of carers, medication crises wrong doses, duplication of doses etc

8. Mother came out of hospital, managed for another 2 years, strongly proactive, compliant, trying to work with services, but Remained on waiting lists for over 18m, then assessment, then therapist would leave, no services, position empty, then someone employed, then maternity leave, never had one therapist for more than two sessions and had repeated needs assessments and no therapy. Therapists did not visit the schools, only the home Constant behavioural ‘emergencies’ which resulted in suspensions

9. Parents more stressed, other son moved to public school, all his activities stopped due to financial constraints, father depressed, staying at work longer and longer, family socially isolated, and eventually mum took S to police station, caught a plane to the Philippines and refused to come back until he was placed in out of home care.

10. S in full time out of home care Parents moved to a smaller house Parents have retained guardianship and visit s regularly Brother off all SSRI medication despite having been diagnosed with atypical autism Mum back at work Family just been for the first holiday in 13 years!

11. Ethical Issues: ? Medication plugging the hole for psychosocial services ? Medication used as a quick fix because psychosocial intervention takes time ? Machine gun or pharmacologically rich approach ? Threw baby out with water In home vs out of home

12. Polypharmacy Literature says polypharmacy leads to: - Increase in drug interactions Decrease in adherence Adverse outcomes for patient “the use of therapeutic agents represents a trade off between benefits of symptoms relief or disease modification that increase quality of life and the risk of short and long term adverse effects” 1 1. Morden and Goodman 2011 Archped

13. 13 SRI NRI DRI 5HT2C m-ACh NOS CYP 2D6 1A2 CYP 3A4 SSRI 6-40 Stahl S M, Essential Psychopharmacology (2000)

14. Drug cocktails Pharmacological rich Multireceptor focus Individualised medication Potential for drug interactions both pharmacodynamic and pharmacokinetic

15. mechanism

16. When serotonin receptor blockade added

17. When noradrenaline blockade is added

18. Summary of receptors and adverse effects drugreceptorCommon adverse and positive effect amitriptyline 11 hypotension Mu Constipation, thirst, blurred vision SERT Bleeding, platelet aggregation NERT ‘pseudoanticholinergic’ dry mouth, constipation, urinary retention 5HT2C Increase satiety, weight gain 5HT Agitation initially, nausea initially,  Hypotension, respiratory effects H1H1 Weight gain, drowsiness clonidine  2  3 Drowsiness, hypotension aripiprazoleD2 Extrapyramidal effects, hyperprolactinemia 5HT2A Decrease positive symptomology 5HT1A Cortical pyramidal neuron, regulates hormones -post synaptic, decreases dopamine release – presynaptic autoreceptor D3 ?cognitive effects naltrexoneMuDecrease pleasure response

19. Practical approach to Medication Setting the stage: Understand family context background, views, prejudices, myths Parents need context, information, time, reactions may vary from angry, denial, guilt, pragmatic acceptance, relief Family issue, not a patient/client issue Medication always one part of a holistic/multidisciplinary plan

20. Considerations: social Is there a responsible primary carer Mental health issues in parents Parental medication history Substance abuse Divorce Extended family /friends views Media/internet influence

21. Medical Provide rationale ( working diagnosis) and information Provide sufficient time for discussion Opportunity to review and discuss again Respectful of parents decision Informed Consent clearly documented Start low and go slow Clear written schedule Available for consultation during trial Monitoring benefits and side effects Emphasise that medication is not forever Discuss how medication would be stopped and what would be the best times to do this

22. Summary Multi disciplinary Multi settings Consistent team approach. No one discipline has the magic bullet. Communication between the team members Medication and at times Polypharmacy has a valuable role in complex behavioural disorders Thorough assessment required Targeted behaviour monitored closely/constant review Family focussed intervention