Treatment algorithm for the use of psychopharmacological agents in individuals prenatally exposed to alcohol and/or with diagnosis of fetal alcohol spectrum disorder (FASD)
Main Article Content
Keywords
Fetal Alcohol Spectrum Disorder, Prenatal Alcohol Exposure, Medication Algorithm, Psychiatric Medication, Psychopharmacological Agents
Abstract
Psychotropic medication treatment of individuals who have experienced prenatal alcohol exposure (PAE) has lagged behind psychosocial interventions. Multiple psychotropic medications are often prescribed for those diagnosed with a range of neurodevelopmental disabilities and impairments of PAE (neurodevelopmental disorder associated with prenatal alcohol exposure and/or fetal alcohol spectrum disorder [ND-PAE/FASD]). Despite the diverse comorbid mental disorders, there are no specific guidelines for psychotropic medications for individuals with ND-PAE/FASD. When prescribed, concerned family members and caregivers of individuals with ND-PAE/FASD reported that polypharmacy, which was typical and adverse effects render the psychotropic medications ineffective. The objective of this work was to generate a treatment algorithm for the use of psychopharmacological agents specifically for individuals with ND-PAE/FASD. The development of decision tree for use to prescribe psychotropic medications incorporated findings from previous research and the collective clinical experience of a multidisciplinary and international panel of experts who work with individuals with ND PAE/FASD, including an algorithm specialist. After multiple meetings and discussions, the experts reached consensus on how best to streamline prescribing along neurodevelopmental clusters. These were subdivided into four ligand-specific, receptor-acting medication targets (hyperarousal, emotional dysregulation, hyperactive/neurocognitive, and cognitive inflexibility). Each cluster is represented by a list of common symptoms. The experts recommended that prescribers first ensure adequate psychosocial and environmental, including sufficient dietary, exercise, and sleep support before prescribing psychotropic medications. Treatment then progresses through three steps of psychotropic medications for each cluster. To support established treatment goals, the most function impairing clusters are targeted first.
References
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23. Lam VY, Raineki C, Ellis L, et al. Interactive effects of prenatal alcohol exposure and chronic stress in adulthood on anxiety-like behavior and central stress-related receptor mRNA expression: Sex-and time-dependent effects. Psychoneuroendocrinology. 2018;97:8–19. https://doi.org/10.1016/j.psyneuen. 2018.06.018
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25. Cho SJ, Lovinger DM, N’Gouemo P. Prenatal alcohol exposure enhances the susceptibility to NMDA-induced generalized tonic-clonic seizures in developing rats. CNS Neurosci Ther. 2017;23(10):808–17. https://doi.org/10.1111/cns. 12756
26. Turgay A, Jain U, Weiss M, et al. CADDRA Guidelines Steering Committee Canadian ADHD Practice Guidelines (CAP-G). Ontario, Canada: Canadian ADD Resource Alliance, Toronto; 2005.
27. Doig J, McLennan JD, Gibbard WB. Medication effects on symptoms of attention-deficit/hyperactivity disorder in children with fetal alcohol spectrum disorder. J Child Adolesc Psychopharmacol. 2008;18(4):365–71. https:// doi.org/10.1089/cap.2007.0121
28. Ozsarfati J, Koren G. Medications used in the treatment of disruptive behavior in children with FASD—A guide. J Popul Ther Clin Pharmacol. 2015;22(1):59–67. Available from: https://www. jptcp.com/index.php/jptcp/article/view/277
29. Frankel F, Paley B, Marquardt R, et al. Stimulants, neuroleptics, and children’s friendship training for children with fetal alcohol spectrum disorders. J Child Adolesc Psychopharmacol. 2006;16(6): 777–89. https://doi.org/10.1089/cap.2006.16.777
30. Dennis JP, Vander Wal JS. The cognitive flexibility inventory: Instrument development and estimates of reliability and validity. Cognit Ther Res. 2010;34(3):241–53. https://doi.org/10.1007/ s10608-009-9276-4
31. Kane B. The use of clozapine in Fetal Alcohol Syndrome. Using Clozapine Today. 2017;1:20–3.
32. Oesterheld JR, Kofoed L, Tervo R, et al. Effectiveness of methylphenidate in Native American children with fetal alcohol syndrome and attention deficit/hyperactivity disorder: A controlled pilot study. J Child Adolesc Psychopharmacol. 1998;8(1):39–48. https://doi. org/10.1089/cap.1998.8.39
33. Young S, Absoud M, Blackburn C, et al. Guidelines for identification and treatment of individuals with attention deficit/hyperactivity disorder and associated fetal alcohol spectrum disorders based upon expert consensus. BMC Psychiatry. 2016;16(1):324.
34. Ghanizadeh A. Systematic review of clinical trials of aripiprazole for treating attention deficit hyperactivity disorder. Neurosciences (Riyadh). 2013;18(4):323–9. Available from: http://www.nsj. org.sa/PDFFiles/Oct13/01Systemic20130005.pdf
35. Hosenbocus S, Chahal R. A review of executive function deficits and pharmacological management in children and adolescents. J Can Acad Child Adolesc Psychiatry. 2012;21(3):223.
36. Chen ML, Olson HC, Picciano JF, et al. Sleep problems in children with fetal alcohol spectrum disorders. J Clin Sleep Med. 2012;8(04):421–9. https://doi.org/10.5664/jcsm.2038
37. Wozniak JR, Fuglestad AJ, Eckerle JK, et al. Choline supplementation in children with fetal alcohol spectrum disorders: A randomized, double-blind, placebo-controlled trial. Am J Clin Nutr. 2015;102(5):1113–25. https://doi.org/ 10.3945/ajcn.114.099168
38. Reimers MJ, La Du JK, Periera CB, et al. Ethanol-dependent toxicity in zebrafish is partially attenuated by antioxidants. Neurotoxicol Teratol. 2006;28(4):497–508. Available from: http://www. sciencedirect.com/science/article/pii/S0892036 206000754
39. Nguyen TT, Risbud RD, Mattson SN, et al. Randomized, double-blind, placebo-controlled clinical trial of choline supplementation in school-aged children with fetal alcohol spectrum disorders. Am J Clin Nutr. 2016;104(6):1683–92. https://doi.org/10.3945/ajcn.116.142075
40. Chagas MHN, Eckeli AL, Zuardi AW, et al. Cannabidiol can improve complex sleep-related behaviours associated with rapid eye movement sleep behaviour disorder in Parkinson’s disease patients: A case series. J Clin Pharm Ther. 2014;39(5):564–66. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/ jcpt.12179
41. Shannon S, Opila-Lehman J. Effectiveness of cannabidiol oil for pediatric anxiety and insomnia as part of posttraumatic stress disorder: A case report. Permanente J. 2016;20(4):108–11. Available from: http://www.ncbi.nlm.nih.gov/ pmc/articles/PMC5101100/
42. Wang X, Zhang K, Yang F, et al. Minocycline protects developing brain against ethanol-induced damage. Neuropharmacology. 2018;129:84–99. Available from: http://www.sciencedirect.com/sci-ence/article/pii/S0028390817305282
43. Cui C, Grandison L, Noronha A. Neuroimmune mechanisms of brain function and alcohol related disorders. Brain Behav Immun. 2011;25:S1–3. Available from: http://www.sciencedirect.com/sci-ence/article/pii/S0889159111000730
44. Simpson TL, Malte CA, Dietel B, et al. A pilot trial of prazosin, an alpha-1 adrenergic antagonist, for comorbid alcohol dependence and posttraumatic stress disorder. Alcohol Clin Exp Res. 2015;39(5):808–17. Available from: https://onlineli-brary.wiley.com/doi/abs/10.1111/acer.12703
2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5®). Washington, DC: American Psychiatric Pub; 2013.
3. Peadon E, Rhys-Jones B, Bower C, et al. Systematic review of interventions for children with fetal alcohol spectrum disorders. BMC Pediatr. 2009;9(1):35. https://doi.org/10.1186/1471-2431-9-35
4. Mela M, Okpalauwaekwe U, Anderson T, et al. The utility of psychotropic drugs on patients with Fetal Alcohol Spectrum Disorder (FASD): A systematic review. Psychiatry Clin Psychopharmacol. 2018:1–10. https://doi.org/10.1080/24750573.201 8.1458429
5. Ipsiroglu O, Berger M, Lin T, et al. Pathways to overmedication and polypharmacy: Case examples from adolescents with fetal alcohol spectrum disorders. In: The science and ethics of antipsychotic use in children. Amsterdam: Elsevier; 2015. pp. 125–48.
6. Ji NY, Findling RL. Pharmacotherapy for mental health problems in people with intellectual disability. Curr Opin Psychiatry. 2016;29(2):103–25. https://doi.org/10.1097/YCO.0000000000000233
7. O’Malley KD, Rich SD. Clinical implications of a link between fetal alcohol spectrum disorders (FASD) and autism or Asperger’s disorder—A neurodevelopmental frame for helping understanding and management. In: Recent advances in autism spectrum disorders—Volume I. London: InTech; 2013.
8. Chasnoff IJ, Wells AM, King L. Misdiagnosis and missed diagnoses in foster and adopted children with prenatal alcohol exposure. Pediatrics. 2015;135(2):264–70. https://doi.org/ 10.1542/peds.2014-2171
9. Valdovinos MG, Henninger-McMahon M, Schieber E, et al. Assessing the impact of psychotropic medication changes on challenging behavior of individuals with intellectual disabilities. Int J Dev Disabil. 2016;62(3):200–11. https://doi.org/ 10.1080/20473869.2016.1177301
10. O’Malley KD, Koplin B, Dohner V. Psychostimulant clinical response in fetal alcohol syndrome. Can J Psychiatry. 2000;45(1):90.
11. Coe J, Sidders J, Riley K, et al. A survey of medi-cation responses in children and adolescents with fetal alcohol syndrome. Ment Health Aspect Dev Disabil. 2001;4(4):148–55.
12. Franklin L, Deitz J, Jirikowic T, et al. Children with fetal alcohol spectrum disorders: Problem behaviors and sensory processing. Am J Occup Ther. 2008;62(3):265. https://doi.org/10.5014/ ajot.62.3.265
13. O’Connor MJ, Shah B, Whaley S, et al. Psychiatric illness in a clinical sample of children with prenatal alcohol exposure. Am J Drug Alcohol Abuse. 2002;28:743–54. https://doi.org/10.1081/ ADA-120015880
14. Henry J, Sloane M, Black-Pond C. Neurobiology and neurodevelopmental impact of childhood traumatic stress and prenatal alcohol exposure. Lang Speech Hear Serv Sch. 2007;38(2):99–108. https://doi.org/10.1044/0161-1461(2007/010)
15. Kodituwakku PW. A neurodevelopmental frame-work for the development of interventions for children with fetal alcohol spectrum disorders. Alcohol. 2010;44(7–8):717–28. https://doi. org/10.1016/j.alcohol.2009.10.009
16. Pliszka SR, Crismon ML, Hughes CW, et al. The Texas Children’s Medication Algorithm Project: Revision of the algorithm for pharmacotherapy of attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2006;45(6):642–57. https://doi.org/10.1097/01.chi.0000215326. 51175.eb
17. Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management Pediatrics. November 2011;128(5):1007–22. https://doi. org/10.1542/peds.2011-2654
18. Wengel T, Hanlon-Dearman AC, Fjeldsted B. Sleep and sensory characteristics in young children with fetal alcohol spectrum disorder. J Dev Behav Pediatr. 2011;32(5):384–92. https://doi. org/10.1097/DBP.0b013e3182199694
19. Price A, Cook PA, Norgate S, et al. Prenatal alcohol exposure and traumatic childhood experiences: A systematic review. Neurosci Biobehav Rev. 2017;80:89–98. https://doi.org/10.1016/j. neubiorev.2017.05.018
20. Perry BD, Pollard RA, Blakley TL, et al. Childhood trauma, the neurobiology of adaptation, and “use-dependent” development of the brain: How “states” become “traits”. Infant Ment Health J. 1995;16(4):271–91. https://doi.org/10.1002/1097-0 3 5 5 ( 1 9 9 5 2 4 ) 1 6 : 4 < 2 7 1 : : A I D -IMHJ2280160404>3.0.CO;2-B
21. Calles Jr JL. Use of psychotropic medications in children with developmental disabilities. Pediatr Clin North Am. 2008;55(5):1227–40. https://doi. org/10.1016/j.pcl.2008.07.002
22. Bandelow B, Zohar J, Hollander E, et al. WFSBP Task Force on Treatment Guidelines for Anxiety, Obsessive-Compulsive and Post-Traumatic Stress Disorders. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of anxiety, obsessive-compulsive and post-traumatic stress disorders—First revision. World J Biol Psychiatry. 2008;9(4):248–312. https://doi.org/10.1080/15622 970802465807
23. Lam VY, Raineki C, Ellis L, et al. Interactive effects of prenatal alcohol exposure and chronic stress in adulthood on anxiety-like behavior and central stress-related receptor mRNA expression: Sex-and time-dependent effects. Psychoneuroendocrinology. 2018;97:8–19. https://doi.org/10.1016/j.psyneuen. 2018.06.018
24. Kable JA, Reynolds JN, Valenzuela CF, et al. Proceedings of the 2013 annual meeting of the Fetal Alcohol Spectrum Disorders Study Group. Alcohol. 2014;48(7):623–30. https://doi.org/10. 1016/j.alcohol.2014.08.002
25. Cho SJ, Lovinger DM, N’Gouemo P. Prenatal alcohol exposure enhances the susceptibility to NMDA-induced generalized tonic-clonic seizures in developing rats. CNS Neurosci Ther. 2017;23(10):808–17. https://doi.org/10.1111/cns. 12756
26. Turgay A, Jain U, Weiss M, et al. CADDRA Guidelines Steering Committee Canadian ADHD Practice Guidelines (CAP-G). Ontario, Canada: Canadian ADD Resource Alliance, Toronto; 2005.
27. Doig J, McLennan JD, Gibbard WB. Medication effects on symptoms of attention-deficit/hyperactivity disorder in children with fetal alcohol spectrum disorder. J Child Adolesc Psychopharmacol. 2008;18(4):365–71. https:// doi.org/10.1089/cap.2007.0121
28. Ozsarfati J, Koren G. Medications used in the treatment of disruptive behavior in children with FASD—A guide. J Popul Ther Clin Pharmacol. 2015;22(1):59–67. Available from: https://www. jptcp.com/index.php/jptcp/article/view/277
29. Frankel F, Paley B, Marquardt R, et al. Stimulants, neuroleptics, and children’s friendship training for children with fetal alcohol spectrum disorders. J Child Adolesc Psychopharmacol. 2006;16(6): 777–89. https://doi.org/10.1089/cap.2006.16.777
30. Dennis JP, Vander Wal JS. The cognitive flexibility inventory: Instrument development and estimates of reliability and validity. Cognit Ther Res. 2010;34(3):241–53. https://doi.org/10.1007/ s10608-009-9276-4
31. Kane B. The use of clozapine in Fetal Alcohol Syndrome. Using Clozapine Today. 2017;1:20–3.
32. Oesterheld JR, Kofoed L, Tervo R, et al. Effectiveness of methylphenidate in Native American children with fetal alcohol syndrome and attention deficit/hyperactivity disorder: A controlled pilot study. J Child Adolesc Psychopharmacol. 1998;8(1):39–48. https://doi. org/10.1089/cap.1998.8.39
33. Young S, Absoud M, Blackburn C, et al. Guidelines for identification and treatment of individuals with attention deficit/hyperactivity disorder and associated fetal alcohol spectrum disorders based upon expert consensus. BMC Psychiatry. 2016;16(1):324.
34. Ghanizadeh A. Systematic review of clinical trials of aripiprazole for treating attention deficit hyperactivity disorder. Neurosciences (Riyadh). 2013;18(4):323–9. Available from: http://www.nsj. org.sa/PDFFiles/Oct13/01Systemic20130005.pdf
35. Hosenbocus S, Chahal R. A review of executive function deficits and pharmacological management in children and adolescents. J Can Acad Child Adolesc Psychiatry. 2012;21(3):223.
36. Chen ML, Olson HC, Picciano JF, et al. Sleep problems in children with fetal alcohol spectrum disorders. J Clin Sleep Med. 2012;8(04):421–9. https://doi.org/10.5664/jcsm.2038
37. Wozniak JR, Fuglestad AJ, Eckerle JK, et al. Choline supplementation in children with fetal alcohol spectrum disorders: A randomized, double-blind, placebo-controlled trial. Am J Clin Nutr. 2015;102(5):1113–25. https://doi.org/ 10.3945/ajcn.114.099168
38. Reimers MJ, La Du JK, Periera CB, et al. Ethanol-dependent toxicity in zebrafish is partially attenuated by antioxidants. Neurotoxicol Teratol. 2006;28(4):497–508. Available from: http://www. sciencedirect.com/science/article/pii/S0892036 206000754
39. Nguyen TT, Risbud RD, Mattson SN, et al. Randomized, double-blind, placebo-controlled clinical trial of choline supplementation in school-aged children with fetal alcohol spectrum disorders. Am J Clin Nutr. 2016;104(6):1683–92. https://doi.org/10.3945/ajcn.116.142075
40. Chagas MHN, Eckeli AL, Zuardi AW, et al. Cannabidiol can improve complex sleep-related behaviours associated with rapid eye movement sleep behaviour disorder in Parkinson’s disease patients: A case series. J Clin Pharm Ther. 2014;39(5):564–66. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/ jcpt.12179
41. Shannon S, Opila-Lehman J. Effectiveness of cannabidiol oil for pediatric anxiety and insomnia as part of posttraumatic stress disorder: A case report. Permanente J. 2016;20(4):108–11. Available from: http://www.ncbi.nlm.nih.gov/ pmc/articles/PMC5101100/
42. Wang X, Zhang K, Yang F, et al. Minocycline protects developing brain against ethanol-induced damage. Neuropharmacology. 2018;129:84–99. Available from: http://www.sciencedirect.com/sci-ence/article/pii/S0028390817305282
43. Cui C, Grandison L, Noronha A. Neuroimmune mechanisms of brain function and alcohol related disorders. Brain Behav Immun. 2011;25:S1–3. Available from: http://www.sciencedirect.com/sci-ence/article/pii/S0889159111000730
44. Simpson TL, Malte CA, Dietel B, et al. A pilot trial of prazosin, an alpha-1 adrenergic antagonist, for comorbid alcohol dependence and posttraumatic stress disorder. Alcohol Clin Exp Res. 2015;39(5):808–17. Available from: https://onlineli-brary.wiley.com/doi/abs/10.1111/acer.12703
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Jul 16, 2020
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Mela, M., Hanlon-Dearman, A., Ahmed, A. G., D. Rich, S., Densmore, R., Reid, D., Barr, A. M., Osser, D., Anderson, T., Suberu, B., Ipsiroglu, O., Rajani, H., & Loock, C. (2020). Treatment algorithm for the use of psychopharmacological agents in individuals prenatally exposed to alcohol and/or with diagnosis of fetal alcohol spectrum disorder (FASD). Journal of Population Therapeutics and Clinical Pharmacology, 27(3), e1-e13. https://doi.org/10.15586/jptcp.v27i3.681
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