Last December, we spoke with Dr. Joshua Feder about repetition in autism therapy. He returns today to speak with us from his practice in Solana Beach, California about autism and medication. Is medication the missing piece for some of his patients? How does he know whether to medicate and what are the complications of using medications? Also, how does he make a diagnosis?
Dr. Feder is the is a father of a grown autistic son, a child and family psychiatrist using the Developmental, Individual differences, Relationship-based (DIR) model and an Expert DIR Training Leader. He is also a faculty member with both the Interdisciplinary Council on Development and Learning (ICDL), the home of DIR/Floortime, and Profectum, and an adjunct faculty with Fielding Graduate University in the PhD program in Infant and Early Childhood Development.
Dr. Feder has a lot of experience in the world of autism. He was in on the first practice parameters for diagnosing and management of autism from the American Academy of Child and Adolescent Psychiatry in 1999, and sits on a policy working group related to autism and intellectual disabilities, having been in discussions about autism and medication for decades.
Dr. Feder has conducted neutral, non-industry based pharmaceutical research funded by the National Institutes of Health
(NIH), and is editor and chief of the Carlat Child Psychiatry Report
, a non-pharma and transparency-based newsletter and continuing education vehicle for child psychiatrists, helping craft training for child psychiatry in the use of medications.
Dr. Feder sees medications as a tool to support a good plan, not to try to make up for an inadequate a plan, which is DIR thinking. He notes that many people are always concerned about the safety of medications and side effects, but people should also be skeptical of many supplements out there which may not be safe. A lot is known about medication and side effects whereas not so much research is out there about some supplements and other substances.
He gives the example of CBD (Cannabidiol from marjuana). There is a lot of hype and marketing but not a lot of solid evidence to support that it works. There is, however, a lot of evidence to support many problems associated with it, and now that people are using it more and more, there are more reports of adverse side effects.
Regression to the Mean and Placebo Effects
Dr. Feder describes how you can start a medication and your symptoms might go away, but it is not necessarily due to the medication. Lots of times symptoms wax and wane. When they get worse and we do something to try to help them and they improve, they might have already peaked anyway. You need to really monitor over time what works, or you could be taking medication that might not be helping. Also, placebo effects may help you feel better regardless of what the medication is doing, but they usually don’t last more than a few weeks.
Dr. Feder points out that good research is hard to come by, especially for those who are on combinations of medications. People are always changing and developing as well, which changes how medications work. It is a process of careful trial and error with a trusted professional to ‘bend your trajectory’ toward a better life. Good research is often hard to find, but when there is more than one study, it is very supportive that a treatment has merit.
Dr. Feder will consider medication if there is a good plan in place but poor progress. When you’re doing everything you can, yet you’re not making headway, he’ll think about medication. Medication might help particular things that get in the way. Emotional dysregulation, poor sleep, poor nutrition, or distractibility could all be things that medication can help. Safety issues are another concern that warrants thinking about medication, such as severe self-injurious behaviour. And sometimes medication makes patients more regulated, which can help them then develop where they were unable to before.
Dr. Feder also talks about how ridiculous it might be to give children Ritalin only to sit still at school. Children are meant to be active and run around. Sometimes cultural expectations make us think our children need medication when it is not necessary. Dr. Feder also discussed some other cultural norms that dictate other behaviours of ours like the Western cultural expectation of sleeping through the night, when as a species humans seem to be meant to sleep in the evening and before dawn and be up at night. Should we really be medicating people to stay asleep?
Dr. Feder likes to talk with parents, see a family at least twice, review records, talk to other treating professionals and teachers, and if possible, do a home visit or get home video, before making a diagnosis and a plan. He usually pitches a diagnosis as an idea that leads to ideas that might help. Diagnostic thinking often evolves as the child grows. It is important to remember that diagnostic labels don’t always help; they can create lowered expectations that prevent children from getting experiences that would help them grow and develop.
You’re better off to ‘presume competence’ and be empathic with patients. There is new research coming out of Fielding Graduate University’s DIR-based PhD program
in Infant and Early Childhood Development that professionals have implicit biases and that they should listen more to parents’ concerns. By simply being aware that we have bias might help to avoid the consequences of that bias. Parents know their children best and should press to find out more if they suspect a challenge with their child.
See the Carlat Child Psychiatry Report on Autism and Medication
If you enjoyed today’s blog post and podcast, please share it on Facebook or Twitter. Also, if you have any questions, comments, or experiences to share, please post them in the Comments section below. Thank you to Dr. Feder for taking the time out of his very busy schedule to discuss the medication dilemma with us today!
Until next week… here’s to affecting autism through playful interactions!