While parents have been encouraged to by wary of SSRIs, and I do not myself concur with how they are used routinely, physical safety is generally not an issue. With SSRIs, while possible to throw a patient “off,” with quoted risks including possible suicidal ideation, this is a mental issue (how does a medicine agree with someone, what “buttons” in the brain might it be pushing), but is not reflective of physical harm to the brain, a true physical toxicity. It is obvious that most of the side effects and most of the issues have come from these agents is how they agreed (or didn’t) with any given individual patient. Even in the few reports suspicious of a true SSRI physical negative, the evidence is open to great debate, and may not sort out from what is called the background noise of patient selection and control of other variables.9, 10, 11 Unfortunately, when listing side effects, the FDA does not make separate categories, and many agents, including aspirin, can look quite terrifying. It has certainly been my experience as a pediatrician, in using SSRIs for many years now, that until we analyze significantly more complex immune and biologic markers, or perhaps genetic markers, there is no simple way to choose what is the best individual SSRI for a child or adult.
Because the goal is to treat a physical dysfunction within the temporal lobes, if an SSRI did not agree with a patient, I did not give up on looking at an SSRI; I just had to adjust and make the right choices. Instead, in treating “depression,” many psychiatrists might try an SSRI, but when that agent doesn’t work, they move onto another class of antidepressant, and many are not looking to evaluate in any way the choice and dosing issues. It has been my experience that the choice of SSRI will change based on the brains state of development, not so much on a child’s age, although in general, while physically safe, younger children may tend to get more hyper on Prozac.
Basing decisions on function, I am always looking to have a child wake up fully refreshed in the morning, having a healthy REM sleep cycle, and each adjustment of change must result progressively in a sharper, brighter child. Combined with other parts of The Goldberg Approach, the goal is ultimately to have a bright child, with a healthy sparkle in the eye, equivalent to any “healthy” child of comparable age. This is an extremely important concept to understand regarding the use of SSRIs and the whole approach to therapy being presented here. In my very early internship, after a few months of working in a very busy newborn nursery, while I learned to do screening exams, in reality I could look at a baby and know if that child was healthy or ill. There is a sparkle in the eyes a baby has, and, in theory, what a healthy child is supposed to have.
The choice of SSRI will likely change over the years. This will not be based on ideas of control of behavior, but it has been my strong experience that as the brain matures and become healthier, the best choice of SSRI will likely change. Very sadly, when you look at trials of medications for “autism,” most trials are based on control of behaviors, control of aggression, control of “autism” symptoms. Even when anticonvulsants—which work by in essence decreasing nerve excitability thereby “dulling” the brain—may seem to have an initial positive effect for some of these children, dulling the CNS cannot in the long run be efficacious for any child. Since in the end we all need our brains working the best they can be, any medications that decrease function, slow down brain excitability, can only be a long-term negative. This is sadly confirmed that even for neurotypical children with epilepsy, anticonvulsants will ultimately lower IQs by a minimum of 5—10 percent (or more). Only SSRIs (in trials with “autistic” children) have shown to result in improvement in cognition and in a child’s IQ and do not in theory carry a long-term physical risk (when used appropriately and judiciously). What caught my attention as I was dealing with chronic fatigue syndrome was that I heard about some adults who had been treated with Prozac, a new antidepressant medication. These adults were waking up rested in the morning. That meant that there was a considerable normalization of function that was occurring. It turns out that when the temporal lobes are underperfused, they are primarily serotonin mediated. Although it is not the whole answer to the problem, it was a tool that was not present with the earlier generation of antidepressants. What I have learned in dealing with both adults and children is that if you can get them so that they are rested when they wake up, their brain is 98 percent where it ought to be.
Reasons for SSRI use:
➢ After combination of dietary elimination and appropriate symptomatic allergy control, antiviral (if indicated), and/or antifungal (if indicated). If child is NOT fully bright and alert, if any residual spaciness, zoniness, or slow cognitive progress consider addition of SSRI.
➢ If hypoperfusion (particularly temporal lobe area) is present or remains on NeuroSPECT.
There is no absolute guideline or theory that says which SSRI will be the best for any given child. Always wait to start (with rare exceptions) until after child is stabilized on diet, antivirals and (if indicated) antifungals. SSRIs will increase blood flow to temporal lobes, by increasing function of those areas. They will have to be adjusted as the brain changes and matures (this has been a fascinating point clinically).
➢ Purpose/goal is to lift fog and zoniness and improve sleep cycles.
➢ If hyperness occurs and does not resolve in four to six days, change SSRI.
When one reviews medication trials for “autism,” sadly the focus is calming behavior, controlling negatives, not improving cognition, ability to learn, etc. Utilizing NeuroSPECT, it may sadly be understood, that many of these medications being used to “calm” the brain and child down may further be shutting down function/flow in the very areas we need to improve.
What should be necessary to ask about every medical treatment or medication being used in these children is whether it results in a child who is brighter eyed, processes better, and functions quicker. In theory are you helping create a potentially healthier brain and child? Are there negatives associated with what has been prescribed? In theory, when treating a child, no negatives are acceptable.It can often be very hard to discriminate between what is behavioral and what is a medical issue. If you get a change where a child is more tuned in and processing better and in turn that child gives the parents or the teacher/therapist a “bad” time, this needs to be dealt with behaviorally, not medically. The time of adjustment, any changes physically (i.e., dietary, illness, allergies), must all be taken into account to sort out medication effects from behavioral or other factors going on.
I see in these children that the better their brain works, the more they initially act out like a two- or three-year-old kid who never had the “reins” put on them. If that’s in the context of the brain working better, it’s not a negative. One must be able to distinguish when a physically healthier, brighter child acts out at times from when a medication change is affecting a child physically or displaying itself in a negative mood or attitude.
It remains a complex process, like judging hyperness, anxiety, nervousness, and all these pieces simultaneously. I think these children are very anxious, I think they are very frustrated, I think they tend to act out a lot. I think they are miserable a lot of the time (if one speaks with older children or adults with similar disorders, their brains hurt them, their bodies hurt them—it has been my overwhelming experience they are not impervious to pain, they are just in a constant level of pain much of the time).
Often the more a medication calms anything down, the more it has the potential to shut off the areas you want to improve. Therefore, what you need to look at, what one really cares about with every medication adjustment or change is, is he or she brighter eyed, better processing, functioning quicker, physically healthier, or is there a negative? A major point with these children or adults is the simple concept of waking up refreshed, as a sign the brain is in a healthier place.
It has been my experience many times over to have a child doing better, processing better, but like any other kid, they’ll have a bad day, they’ll act out. If decisions are made on the basis of �
�we want a kid controlled and calm” (sadly still today, the “goal” of many therapists), you’re never going to get the brain working right. However, if one makes a medication change, and you’re getting a hyper kid, an irritable child, an ongoing negative, we don’t want that change, and choices must be reevaluated. One must reconsider what the options are. But, if you get a change where the child, he or she is more tuned in, processing better, beginning to function as a “younger” child, and then causes problems (when he or she couldn’t do so before), then that needs to be dealt with behaviorally (dealing with a child psychosocially, developmentally, age appropriately), not as “autism /PDD” and not as a medical problem.
A key point remains always interpreting where a child is psychosocially, developmentally, then dealing with that child, behaviorally, parentally as that child (for where they are developmentally—not their current chronological age), not the misconception of “autism/PDD—retardation.” If a child is functioning bright and acting out, then you don’t want to reinforce that, you don’t won’t to treat them like an infant and “redirect” or “refocus” them; instead you want to empower parents to act in a more normal manner.
When a child is being good, they deserve a response to positive reenforcements (important with any child). But if a child is misbehaving, a time-out (or for an older child withdrawal of a privilege or privileges) may be far more normal discipline for that parent and child. Sadly, part of the principles of any one discipline, is what does it cost that child, versus what they have gained. Children are bright enough to evaluate (as we do) what they lose (versus what they’ve gained). Any “behavioralist” giving advice to the parents of a child being treated appropriately has to understand the complete difference (again where is a child psychosocially, developmentally).
Here again is the issue of child recovering from a disease versus a behavioral or developmental disorder that in theory doesn’t really change. As a physician, you need to constantly sort out and make the distinction: Is there a negative behavior because he’s just acting out like a “typical” child, or is it negative behavior because you are throwing him off medically?
SSRIs—Neurotropics sample treatment
(always start low, work up at two- to three-week intervals —or longer—toward optimal dosage)
Zoloft
Large variability in dosing
5–10 mg/yr of age children
Paxil
Approximately 1 mg/yr of age in children
Do not exceed 40 mg in an adult
Celexa
Generally seems to be about 2mg/yr of age
Do not exceed 40 mg in an adult
Prozac
Approximately 1mg/yr of age
Do not exceed 40 mg in an adult
(Wellbutrin, Strattera, EffexorXR, or Tenex as indicated in specific cases)
Gamma Globulin Therapy
The idea of what is called gamma globulin therapy (IgG product) has been around for decades. At first there was significant risk warning about the IV form (IVGG), but that has thankfully become a very small (but still real) factor today. On the other hand, IM (intramuscular) use, while considered safer (extra step of acidification and processing), was not felt to be as efficacious (if at all) for serious disorders. Retrospectively the often “anecdotal” success of a “shot of gamma globulin” to boost someone’s immune system while they traveled to Europe or a foreign country, which was done by a lot of clinicians, was never really proven in studies to be efficacious. As with any therapy application, too often, without an absolute guideline or marker, we are skeptical rather than inquisitive.
The debate regarding the efficiacy of gamma globulin, the ongoing fights regarding sugar and hyperness in children, and many other similar battles were all part of an early learning lesson—that what might be efficacious, and certainly accepted anecdotally as helpful or real, may not be easily or readily proven in formal, controlled studies. These were all clinical lessons, establishing for this author acceptance of the principal that there may be subpopulations for which a therapy may be significant, but not validated when looking at the whole / entire population. Especially when looking at these and other complex immune disorders, understanding, classifying the correct subpopulations is going to be critical to define successful therapies.
It is obvious over years of working with patients with this that some will benefit greatly (not just those with absolutely low IgG levels to begin with), but it was not going to be an answer for this disorder. In turn, expecting help, but not cure or resolution, unless absolutely indicated, I never wanted to use IVGG (even as the risk has thankfully become much smaller). Since IVGG is a pooled plasma product (as is IMGG), even with improved screening and virus neutralization procedures, the IVIG product carries some risk of transmitting viruses (particularly a retrovirus) and other biological agents.
It is well documented that experiences during infants’ and toddlers’ first months and years of life have a major impact on the evolving formation of neural connections, the laying down of “tracks” in developing brains. We develop brains over time.
When there has been a disruption in this process, such as the neuroimmune shutdown discussed in this book, it is not only important to help the correct areas of the brain—to open up, restore function—but then we must help re-create learning, developmental points missed in those early years. With brain functioning, the more this is done in a natural manner, helping a child not only learn but also experience or generalize something is a key to going back and “filling in the holes.” We take it for granted, but these learning experiences lay the groundwork for that child to move on to higher learning, areas of comprehension, and so forth.
Back to the basic research, with the general acceptance that “experience shapes the developing structure of the brain” and the knowledge that the human body, including the brain, is made up of cells, it is only logical to start from a point that initially those cells may be somewhat organized, but they are nowhere near the level of function, the level of interconnections and “tracks” that will be need to function effectively as that child matures to become an adult. The idea that we cannot expect to reestablish or redevelop those connections is the ongoing mistake of the autism diagnosis and treatment. The fact that the brain is now known to develop into adulthood is a key reason for some optimism, even in older children.
Studies in brain physiology confirm that brain cells were perfectly designed for making connections. The cells signal each other; these electrical impulses travel down the cell and then are completed cell to cell by special chemicals (such as serotonin). It is the repeated activation and use of these tracks that ultimately results in a “mature” educated brain.
Yes, there is a reason for homework. It helps to develop these brain tracks.
We must begin thinking of these children as potentially healthy productive teenagers, and adults. That means that we have to work to help them have a healthy potentially recoverable brain, not come from an assumption that somehow mysteriously that brain is predamaged, cannot be expected to function in a normal manner. I wonder how many of us would have succeeded if parts of our brain were shut down. Think of how many of the current “mixed” or “quiet” ADHD children are going to school as “space cadets.” I feel extremely sorry for the teachers being asked to try and educate these children. Lack of recognition of the medical origin and severity of their condition may be a factor in what is looked upon as the “dumbing down” of our society. Maybe the common ideas of video games, parenting, teaching, and diet are factors, but what if they are not really the major ones at all? No wonder things do not seem to be getting any better for parents or children.
When approaching therapy, you must only change one variable in a patient at a time if you are going to have any controlled way of judging what the agent/therapy is doing. As I have expressed to parents many times, I would not have the general optimism, the literal expectation of a high level of success, if I did not go step by step. Thi
s principle seems to be forgotten with these children.
As much as I understand this disorder and have had physiologic insight (the NeuroSPECT) to the brain’s actual dysfunction, I would not have had a chance to understand the many variables of a child if I did not go step by step. These principles do not seem to apply to most therapists recommending agents or advising parents on these children. Without following this approach, it is safe to say any therapist will find it impossible to sort out what is a physical change or a positive effect on the brain, from behavioral and other multiple variables in a potentially “normal” child.
When a three- or four-year-old, or a seven- or eight-year-old child starts acting out with the “terrible twos,” one must critically be able to sort out good behavioral changes, likely normal developmental points, from dysfunctional or bad ones. As a pediatrician, as a person, as a parent, contrary to background or training, it became obvious in the early months of working with these children that they were children. How could a supposedly miswired, damaged brain pick up not where that child might be in chronological age, but developmentally, for many children, they would pick up back at that eighteen-month, two-year-old level, where they had in reality shut down (not been born developmentally or genetically miswired by some mysterious process). Some children of course were higher in function or abilities, but if not achieved in a normal way, were likely to have significant holes in their education or development.
I realized as a pediatrician to base educational and behavioral goals for the parents and the child, based on where they were developmentally (low points), not chronologically. As really applies to all of us, we do much better when all parts of our brain are working in balance, not underactive, not overactive. Using the NeuroSPECT, blood markers, and physiologic functioning helps guide choices or changes in therapy. Starting or stopping therapy/therapies without any attempt at objective markers, in my years of experience, is a very large mistake.
The Myth of Autism Page 12