Pharmacological management of behavioural problems in children with acquired brain injury. A/Professor A Vance

Transcription

1 Pharmacological management of behavioural problems in children with acquired brain injury

2 Outline of presentation 1. The key types of acquired brain injury behavioural problems 2. A useful clinical model for understanding these problems 3. Useful medication approaches

3 1. The key types of acquired brain injury behavioural problems - social environment is making inappropriate demands on him/her - learned and/or internalized maladaptive ways of being and coping in their environments - direct result key area of abnormal brain function S L B

4 1. The key types of acquired brain injury behavioural problems - oppositional defiant problems - attentional problems - decreased verbal memory, expressive language, visual memory, visuospatial executive functioning, visuomotor skills

5 1. The key types of acquired brain injury behavioural problems - oppositional defiant disorder - ADHD, combined type -OCD - GAD/SAD/SoPh - depressive disorders - stereotypic movement disorder symptoms - psychotic disorder (disorganised schizophrenia) - developmental coordination disorder - hyperacusis

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7 2. A useful clinical model for understanding these problems Prevalence of psychiatric disorder(s)

8 2. A useful clinical model for understanding these problems Specific psychiatric disorders

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12 2. A useful clinical model for understanding these problems Executive functioning Response inhibition: Working memory: motor and cognition optimise response speed and accuracy verbal and visuospatial optimise span and strategy

13 2. A useful clinical model for understanding these problems Mood dysregulation: Arousal dysregulation: decrease irritability increase emotional salience optimise physiological arousal optimise habituation

14 3. Useful medication approaches Response inhibition: motor and cognition speed and accuracy stimulant medication -linear dose response clonidine higher dose Working memory: span strategy stimulant medication -inverted parabolic response stimulant medication -linear dose response clonidine higher dose

15 3. Useful medication approaches Mood dysregulation: irritability emotional salience stimulant medication SSRI TCA antipsychotic medication stimulant medication SSRI? TCA?

16 3. Useful medication approaches Arousal regulation: physiological arousal habituation response clonidine benzodiazepines TCA antipsychotic medication clonidine benzodiazepines TCA? antipsychotic medication?

17 3. Useful medication approaches -start low, go slow, finish slow, although same optimal doses are suggested -children versus adults: higher doses with more frequent dosing NB: increased distribution and more rapid clearance NB: daily compliance issues NB: non-linear kinetics due to saturation elimination SSRIs/higher doses sodium valproate

18 -children versus adults: NB: varying pharmacodynamics moclobemide short t1/2 but hours effects antipsychotics receptor saturation differences antidepressants and delayed response, antipsychotics prolonged effects, tolerance at a level

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22 Remember -the psychological and social context in which the child is immersed is important as well. -most importantly, we want the child to be in a learning environment that is consistent and attuned, sensitive and responsive -key developmental phases lead to changes in pharmacokinetic (especially distribution and clearance) and pharmacodynamic (especially short and longer-term effects at primary and secondary levels) properties -each child needs complete re-review every six months

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