In 2017 when the first 99 Day Journey began, I discovered an article called Team to develop the first medication guidelines for FASD at the University of Saskatchewan (Canada).
The idea is to examine the various complications that people with FASD face, such as inattention, difficulty planning, challenges in relational situations, and issues with mood and sleeping.
Then, the group will recommend medical guidelines instructing doctors what to prescribe “so that when a physician says to his patient, ‘I need you to take this medicine,’ they’re going to be doing it from an informed position,” Dr. Mansfield Mela, head of the psycholegal and FASD research lab at the U of S, told CBC Radio’s Saskatoon Morning.
In 2019 I contacted the University to see if there was a follow-up or a report of results or next steps as it sounds promising. And while the only response I got was that my enquiry had been sent to the research team, I did belong to a group that was asked to test the initial algorithm.
I gave a copy of the algorithm to the maiden’s psychiatrist at the time, but she didn’t seem interested. So once again, professionals failed to take the lived experience of patients with FASD and their caregivers. And in this case a team of professionals. It was disheartening to say the least. It’s been a few years since it’s introduction, so what is the history and how is it doing?
Psychotropic Medication Algorithm released in 2020
According to an article from CanFASD :
Dr. Mela and a team of 12 multidisciplinary international experts (see list below) have spent over 2 years developing a decision-tree style medication algorithm to guide prescribers as they see patients with Fetal Alcohol Spectrum Disorder / Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (FASD/ND-PAE).
This algorithm is the first-ever treatment recommendation for psychotropic medications for FASD/ND-PAE. It is based on all available evidence (albeit very limited), which was consolidated in a recently published systematic review (Mela M, Okpalauwaekwe U, Anderson T, Eng J, Nomani S, Ahmed A, Barr AM. The utility of psychotropic drugs on patients with Fetal Alcohol Spectrum Disorder (FASD): a systematic review. Psychiatry and Clinical Psychopharmacology. 2018:1-10).
From there, the algorithm was developed by considering the evidence and incorporating the clinical perspective of the expert panel.
Now that the algorithm is developed, it needs to be evaluated to understand the effectiveness and allow for improvements for future iterations.
This medication algorithm is intended for individuals with a primary diagnosis of:
- Neurodevelopmental Disorder associated with Prenatal Alcohol Exposure
- Fetal Alcohol Syndrome Disorder (with or without sentinel facial features)
- Alcohol-related Neurodevelopmental Disorder
As a clinician, it is important to identify the primary “clusters” (domains) to target treatment. The first line of treatment is reserved for the cluster with the most impairing effect on functioning.
After an adequate trial of the medications from the first line, medications from the second line can be tried, followed by other traditional guidance.
Finally, if the first or second line medications are not effective, the adjunct treatment may be considered from the list in the algorithm.
The clusters include:
- Hyper-arousal (with hypervigilance, aggression, insomnia, irritability, agitation, anger, anxiety, tension, reduced pain threshold)
- Emotional dysregulation (with mood swings, excitability, anxiety, depression)
- Hyperactivity/Neurocognitive (with restless movements, impulsiveness, inattention, distractibility and executive dysfunction)
- Cognitive inflexibility with impaired perspective taking, poor abstraction, low frustration tolerance, poor social skills and impaired reasoning and reality testing
Psychotropic Medication Algorithm Panel of Experts
- Mansfield Mela University of Saskatchewan, Depart of Psychiatry, CA
- Ana Hanlon-Dearman University of Manitoba, Faculty of Medicine, CA
- AG Ahmed Royal Ottawa Hospital, CA
- Susan D. Rich Child Psychiatrist, USA
- Rod Densmore Urban Aboriginal Health Centre, Kamloops, B.C, CA
- Dorothy Reid CanFASD Research Network
- Alasdair Barr University of British Columbia, Depart of Pharmacology, CA
- David Osser Harvard Medical School, USA
- Tara Anderson University of Saskatchewan, College of Medicine, CA
- Bola Suberu Staff Psychiatrist, Medicine Hat Regional Hospital, CA
- Osman Ipsiroglu University of British Columbia, Faculty of Medicine, CA
- Hasu Rajani University of Alberta, Faculty of Medicine & Dentistry, CA
- Christine Loock University of British Columbia, Faculty of Medicine, CA
It’s important to note Dr. Mela states that medication is not the answer – it is an adjunct. Social support, sleep, nutrition and exercise are the first approaches. If, after examining each of those areas and putting into place interventions or new routines, there is not improvement, then looking at medication can be the next step.
Webinar and Podcasts on with Dr. Mela
Jeff Noble (Noble Initiatives/FASD Caregiver Success) held a webinar with Dr. Mela in April 2020, to talk about the algorithm. Unfortunately it is no longer available to view. He did however interview him in 2020 for his podcast The FASD Success Show and they discussed the algorithm.
Grab a PDF Copy: Psychotropic-Medication-Algorithm-for-FASD
There was a retrospective review of the algorithm published in November 2021.
Durr, MR.R., Petryk, S., Mela, M. et al. Utilization of psychotropic medications in children with FASD: a retrospective review. BMC Pediatr 21, 512 (2021). https://doi.org/10.1186/s12887-021-02986-5
The primary objective was to compare the proposed treatment algorithm retrospectively to actual treatment in a real-world FASD pediatric practice. The secondary objective was to refine the description of symptom clusters which will be targeted with treatment.
The present medication algorithm is promising but requires further flexibility, refinement, and validity testing to accommodate the range of presentations in children and the variance therein. The algorithm is especially strong when predicting FASD single-cluster cases, but the need for physician guidance is evident when prescribing in more complex multi-cluster cases.
For those as yet unclassified symptoms, we propose the following: sleep onset difficulty as hyperarousal; gender dysphoria and obsessive compulsive disorder as cognitive inflexibility; grief as emotional regulation; and autism spectrum disorder as hyperactive/neurocognitive.
Next steps could include more validity studies like this one, but across more age groups including adults. Ultimately, the algorithm requires a large prospective randomized controlled trial amongst several physicians to test its actual utility.
Continued prospective analysis of the emotional behavioural challenges in children and youth with FASD is recommended to further refine the validity of the symptom clusters.
A psychotropic medication algorithm for use in FASD is undoubtedly of great interest to clinicians and to families. Individuals with FASD are already particularly vulnerable and a medication algorithm is greatly needed to guide less experienced physicians who provide medical care. An algorithm could increase physician confidence to make informed medication choices, to prevent over-medication and ultimately lead to the most appropriate psychotropic medication treatment for individuals with FASD.
CanFASD published questions that Dr. Mela has been asked about medication and the algorithm along with answers. Questions include:
- Non pharmaceutical approaches
- Side effects
- No diagnosis or managing multiple diagnoses
- Reducing medications
- Dosing for effectiveness
There is also a list of questions and answers for:
- FASD and anxiety
- Hyperactivity and sleep
- Cognitive inflexibility
- Identifying symptom clusters
Please note I am not a medical professional. I am sharing my journey and providing links to information I feel is from credible sources. ALWAYS seek out professional guidance.
Check back tomorrow as we shift gears on our 99 day journey.