Слайд 2
Goals for Today
Following the workshop, participants will be
able to:
Discuss basic neurobiology, neurotransmitters, and brain functioning.
Identify different
medications and their mechanisms of action.
Discuss the interaction of neurobiology, medication, and Play Therapy.
Identify how beneficial effects of medication may facilitate Play Therapy.
Utilize Play Therapy techniques to compensate for the side effects of medications.
Develop an individualized Play Therapy plan for each medicated child.
Слайд 5
Nervous System (cont)
Sympathetic NS
Arouses
(fight-or-flight)
Parasympathetic
NS
Calms
(rest and digest)
Слайд 6
Endocrine System
The Endocrine System is the body’s slow
chemical communication system. Communication is carried out through hormones
synthesized by a set of glands.
Слайд 7
The Basic Brain
Self-regulation, problem solving, goal setting, &
social cognition
Vision and perception
Sensory motor perception, &
spatial abilities
Hearing, language,
memory, & social emotional function
Слайд 8
Brainstem
The Thalamus [THAL-uh-muss] is the brain’s sensory switchboard,
located on top of the brainstem. It directs messages
to the sensory areas in the cortex and transmits replies to the cerebellum and medulla.
Reticular Formation is a nerve network in the brainstem that plays an important role in controlling arousal.
Слайд 9
The Limbic System is a doughnut-shaped system of
neural structures at the border of the brainstem and
cerebrum, associated with emotions such as fear, aggression and drives for food and sex. It includes the hippocampus, amygdala, and hypothalamus.
The Limbic System
Слайд 10
The “little brain” attached to the rear of
the brainstem. It helps coordinate voluntary movements and balance.
Cerebellum
Слайд 11
Amygdala
The Amygdala [ah-MIG-dah-la] consists of two lima bean-sized
neural clusters linked to the emotions of fear and
anger.
Слайд 12
Hypothalamus
The Hypothalamus lies below (hypo) the thalamus. It
directs several maintenance activities like eating, drinking, body temperature,
and control of emotions. It helps govern the endocrine system via the pituitary gland.
Слайд 13
The Cerebral Cortex
The intricate fabric of interconnected neural
cells that covers the cerebral hemispheres. It is the
body’s ultimate control and information processing center.
Слайд 14
Functions of the Cortex
The Motor Cortex is the
area at the rear of the frontal lobes that
control voluntary movements. The Sensory Cortex (parietal cortex) receives information from skin surface and sense organs.
Слайд 15
Brain Growth
AGE BRAIN
WEIGHT (GRAMS)
20 WEEKS GESTATION 100
BIRTH 400
18 MONTHS 800
3 YEARS OLD
1100
ADULT 1300 - 1400
Слайд 16
Brain Changes
At birth, most neurons the brain
will have are present (approx. 100 billion neurons)
By age
2 years, brain is 80% of adult size
What keeps growing?
Other brain cells (glia)
New neuron connections
approx. 1000 trillion connections by age 3 yrs.
Слайд 17
Brain Changes (cont)
Overproduction of neurons and connections among
neurons
Selective reduction of neurons and connections among neurons
Waves of
intense branching and connecting followed by reduction in neurons
Before birth through 3-years-old
Again at 11- or 12-years-old
Слайд 18
Brain Changes (cont)
Anatomical studies of brain development show
Occipital lobes show earliest pruning
Frontal and Temporal lobes
show growth of neural connections longer than other areas of the brain…through 3 years old
Frontal and Temporal lobes show pruning of connections longer than other areas of the brain
Greatest change between 2 years and 5 years
Слайд 19
Brain Changes (cont)
Myelin & Age Changes
Speed of
connection and conductivity
Begins at birth, rapidly increases to 2-years
old
Continues to increase more slowly through 30-years-
old
Слайд 20
Brain Changes - Critical Events (Toga & Mazziotta,
2000)
Слайд 21
Brain Changes and Important Developments
Brain areas with longest
periods of organization related to…
self-regulation,
problem-solving,
language/communication
Social bonding
Most vigorous
growth, pruning, connecting, and activity occurs between 1-1/2 years through 3 or 4 years old.
May be one of the most important periods for developing self-regulation, problem-solving, social-emotional, and language/communication behaviors.
Слайд 22
Impacting Brain Development
Genes form neurons, connections among major
brain regions.
Environment and experience refines the connections; enhancing some
connections while eliminating others.
Brain development is “activity-dependent”
Every experience excites some neural circuits and
leaves others alone.
Neural circuits used over and over strengthen,
those that are not used are dropped resulting in
“pruning”.
Medication ?????????????????
Слайд 23
Brain Areas and Anatomical Development
Brainstem (0-1)--Regulation of arousal,
sleep, and fear
Diencephalon (1-3)--Integration of sensory input and fine
motor skills
Limbic System (3-8)--Emotional states and emotional regulation, social language, interpretation of non-verbals
Cortical Areas (8-adult)--Abstract cognitive functioning, integration of socio-emotional information
Слайд 24
Brain Areas and Anatomical Development
Brain stem and Diencephalon
are harder to change if poorly developed.
Слайд 25
Normal Development and Regulation
Consider:
The Individual
Attachments
Relationships
Culture
Environment
Genetics
Produces Functional & Regulated Affect/Behavior
Слайд 26
“DIR” Model (Greenspan & Wieder, 1997; Willis, 2007)
Developmental
bio-psychosocial model
Developmentally-based
Individual differences
Relationship focused
Слайд 27
Functional Emotional Developmental Levels (Greenspan & Wieder, 1997)
2-3
mon Shared Attention
3-5 mon Engagement
6-9 mon 2-way Intentional Communication
12-18
mon Behavioral Elaboration
Complex, non-verbal, gestural
communication patterns
24-36 mon Representational Communication
Ideas, Words
36-48 mon Emotional Thinking
Linking ideas and thoughts
Слайд 28
Individual Differences
Sensory Processing systems
Cortical processing systems
– Auditory
–
Visual-spatial
– Intelligence
– Memory system
Motor output processes
Слайд 29
Relational Context in Early Childhood
Parent – Child Interactions
Patterns
of Attachment, Cooperation, Conflict-doing, conflict-resolution Regulation of negative &
positive affects, Intimacy communication.
Sibling and Peer Relationships
Birth order, Sibling spacing, Cooperation patterns,
Conflict processes, Peer experiences and opportunities.
Слайд 30
Relational Context in Early Childhood
Socio-Emotional Co-Regulation
Co-regulation of emotions
–
Separation anxiety & fears, Anger & frustrations, Disappointment
Intimate available
relational individual
Cultural Patterns
Parenting styles, Childcare variations, Social units & Multiple early relationships, Older children involvement in child-rearing, Imitative roles, Toys and play
Слайд 31
Adaptive Functioning (Shore, 2001, 2009)
Слайд 32
The Right Brain
The right brain,
according to Schore (2000 and 2009b)
is comprised of
a
lateral tegmental circuitry, which controls negative emotions, avoidance mechanisms, and passive coping
a ventral tegmental circuitry, which controls positive emotions, approach mechanisms, and active coping
Слайд 33
Order of Activation
The autonomic
nervous system, providing sensory information;
amygdala, which generates fight,
flight, and freeze responses;
cingulate, which interprets social cues;
orbitofrontal cortex, which provides executive control.
Слайд 34
The Ventral System
Schore (2000,
2009b) states, when attachment is disrupted or fails to
occur (i.e., lacks appropriate stimulation), it is the ventral tegmental circuitry that is impacted by dysfunctional patterns of relating; hence, the approach process is disrupted and avoidance process goes unaffected.
Слайд 35
What’s Functional?
3 Types of Self-Regulation
Emotional Self-Regulation--between self and
caregiver (self & other).
Behavioral Self-Regulation--the ability to initiate/inhibit behavior
appropriate to context.
Sensory Modulation--the ability to regulate one’s reactivity (responsiveness) to sensory input.
Слайд 36
Neurobiology and Attachment
Secure Attachment- a person capable of
emotional self-regulation and has the ability to cope with
stress
Secure Attachment in Neurobiological Formation: healthy, consistent, and complete development of the orbitofrontal cortex, ventromedial prefrontal cortex, and connections in to subcortical regions of the brain.
Слайд 37
Attachment Neurobiology Process
Слайд 38
Polyvagal Theory
The more primitive branch elicits immobilization behaviors
(e.g., feigning death), whereas the more evolved branch is
linked to social communication and self-soothing behaviors.
Слайд 39
Polyvagal Theory
The vagus nerve is a component of
the autonomic nervous system
Originates in the medulla
Two (2)
branches
Associated with a different adaptive behavioral strategy
Inhibitory in nature via the parasympathetic nervous system
The vagal system is in opposition to the sympathetic-adrenal system, which is involved in mobilization behaviors
Слайд 40
Polyvagal Theory
Dorsal branch
unmylenated
primal survival strategies
freezing
Ventral branch
Mylenated
A sophisticated
system of behavioral and affective responses to an increasingly
complex environment
Regulates of the sympathetic “fight or flight”
Social Communication, Calming, Self-soothing
Can inhibit or disinhibit the limbic system
Слайд 41
Okay, So Let’s Consider Dysfunction and Dysregulation?
The Dysregulated
Brain Has a Mind of Its Own!!!!!!
What’s Leads to
Dysfunction?
Abnormal Development
Attachment Disturbances
Direct Physical Brain Trauma
Слайд 42
Abnormal Development and Dysregulation
Consider:
The Individual
Attachments
Relationships
Culture
Environment
Genetics
Produces Dysfunctional & Dysregulated Affect/Behavior
Слайд 43
Attachment Trauma/Disturbances
Impairments in the development of the orbitofrontal
and ventral prefrontal areas.
Lead to:
Attachment Disorders (Insecure/ Disorganized)
High
risk for PTSD and relational violence
Chronic Disturbance in Affect Regulation (Axis 2)
Chronic Stress (Anxiety, Depression)
Слайд 44
Right Brain Development: Affect Regulation (Schore, 2001)
Amygdala inhibition
by orbitofrontal regions
“Amygdala hijacking” – fight response
Hippocampus memory systems
and Autonomic Nervous System (ANS)
Consequences of Trauma
– Poor affect regulation
Слайд 45
Traumatic Brain Injury
Childhood illnesses (high fevers, meningitis)
Accidents or
Physical Abuse
???? Medications ??????
Слайд 46
The Neurochemical Origins of Disruptive Behaviors
Those related to
dopamine [DA] and aggression, irritability, hyperactivity, and problems with
attention and motivation;
Those related to norepinephrine [NE] and negative emotions and withdrawal;
Those related to serotonin [5HT] and impulsivity.
A fourth category, gamma-aminobutyric acid [GABA], is not usually responsible for disruptive behaviors, but may be involved in regulating these behaviors.
Слайд 47
Disruptive Behaviors, Neurotransmitters, and Brain Regions
Emotional regulation is
connected to the limbic system and prefrontal cortex (Wise,
2004) and is facilitated by DA and NE pathways.
Motivation is connected to the striatum and prefrontal cortex (Aarts, van Holstein, & Cools, 2011) and is facilitated by DA pathways.
Attention and hyperactivity are connected to the lateral prefrontal cortex, dorsal anterior cingulate cortex, caudate, & putamen (Bush, Valera, & Seidman, 2005) and are facilitated by DA and NE pathways.
Слайд 48
Disruptive Behaviors, Neurotransmitters, and Brain Regions (cont)
Impulsivity is
connected to the dorsolateral prefrontal cortex, orbitofrontal cortex, and
anterior cingulate cortex (Adinoff et al., 2003; Royall et al., 2002) and is facilitated by DA and 5HT (Dagher & Robbins, 2009).
Finally, the previously mentioned neurotransmitters are excitatory in nature, while GABA is inhibitory in nature and connected to all levels of the central nervous system (Levy & Degnan, 2012).
Слайд 49
Another Point
We Now Have a Big Problem!
Слайд 50
The ACE Study (Anda et al., 2005; CDC,
1998-2010; Edwards et al., 2005)
Adverse childhood experiences are
the most basic cause of health risk behaviors, morbidity, disability, mortality, and healthcare costs
Traumatic events----Prolonged alarm reaction-----Altered neural systems
Altered cardiovascular regulation
Behavioral impulsivity
Increased anxiety
Increased startle response
Sleep abnormalities
Слайд 52
Stress, the Brain, & the Body
Stress is the
set of changes in the body and the brain
that are set into motion when there are threats to physical or psychological
Under threat, the limbic system engages and the frontal lobes disengage. When safety returns, the limbic chemical reaction stops and the frontal lobes re-engage.
(van der Kolk, B., 2005)
Слайд 54
Early Childhood Disturbances from Trauma and Risk (ACE
Study)
Regulatory disturbances
PTSD
Oppositional Defiant Disorder
Conduct Disorder
ADHD
Anxiety and Depression
Attachment disturbances
Developmental delays
Слайд 55
The Continuum
Attachment Disturbance
ADHD, Bipolar Disorder
Oppositional Defiant
Conduct Disorder
Personality Disorder
Слайд 56
What’s The Point?
We Now Have a Neurobiological Maze,
Which is Difficult to Solve?
And
Medications Can Simplify the Maze
or Complicate Maze!
Слайд 57
Neurotransmitters
Categorized into three major groups:
amino acids (glutamic
acid, GABA, & glycine)
(2) peptides (vasopressin, somatostatin, & neurotensin)
(3) monoamines (norepinephrine NA, dopamine DA & serotonin 5-HT) plus acetylcholine (ACh).
Workhorse neurotransmitters of the brain are glutamic acid (glutamate) and GABA.
Слайд 58
Neurotransmitters & Function
Acetylcholine - voluntary movement of the
muscles, learning, & memory
Norepinephrine – alertness, wakefulness, & arousal
Dopamine - voluntary movement, emotional arousal, & learning, attention
Serotonin - memory, emotions, wakefulness, sleep, hunger, & temperature regulation
GABA (gamma aminobutyric acid) - motor behavior & mood
Glutamate - memory
Glycine - spinal reflexes & motor behavior
Neuromodulators - sensory transmission-especially pain
Слайд 59
Neurotransmitter (Excitation vs. Inhibition)
EXCITATORY
Acetylcholine
Aspartate
Dopamine
Histamine
Norepinephrine
Epinephrine
Glutamate
Serotonin
INHIBITORY
GABA
Glycine
Слайд 60
Dopamine (DA)
Dopamine is transmitted via three major pathways.
The first extends from the substantia nigra to the
caudate nucleus-putamen (neostriatum) and is concerned with sensory stimuli and movement. The second pathway projects from the ventral tegmentum to the mesolimbic forebrain and is thought to be associated with cognitive, reward and emotional behavior. The third pathway, known as the tubero-infundibular system, is concerned with neuronal control of the hypothalmic-pituatory endocrine system.
Слайд 61
Serotonin (5-HT)
The principal centers for serotonergic neurons are
the rostral and caudal raphe nuclei. From the rostral
raphe nuclei axons ascend to the cerebral cortex, limbic regions and specifically to the basal ganglia. Serotonergic nuclei in the brain stem give rise to descending axons, some of which terminate in the medulla, while others descend the spinal cord.
Слайд 62
Norepinephrine (NE)
Many regions of the brain are supplied
by the noradrenergic systems. The principal centers for noradrenergic
neurons are the locus coeruleus and the caudal raphe nuclei. The ascending nerves of the locus coeruleus project to the frontal cortex, thalamus, hypothalamus and limbic system. Noradrenaline is also transmitted from the locus coeruleus to the cerebellum. Nerves projecting from the caudal raphe nuclei ascend to the amygdala and descend to the midbrain.
Слайд 63
Gamma-aminobutyric acid (GABA)
GABA is the main inhibitory neurotransmitter
in the central nervous system (CNS). GABAergic inhibition is
seen at all levels of the CNS, including the hypothalamus, hippocampus, cerebral cortex and cerebellar cortex. As well as the large well-established GABA pathways, GABA interneurons are abundant in the brain, with 50% of the inhibitory synapses in the brain being GABA mediated.
Слайд 64
Glutamate
In the normal brain the prominent glutamatergic pathways
are: the cortico-cortical pathways; the pathways between the thalamus
and the cortex; and the extrapyramidal pathway (the projections between the cortex and striatum). Other glutamate projections exist between the cortex, substantia nigra, subthalmic nucleus and pallidum. Glutamate-containing neuronal terminals are ubiquitous in the central nervous system and their importance in mental activity and neurotransmission is considerable.
Слайд 65
Acetylcholine (Ach)
There are three Acetylcholine pathways in the
CNS. (a) The Pons to thalamus and cortex, (b)
Magnocellular forebrain nucleus to cortex, & (c) Septohippocampal. In the central nervous system, ACh has a variety of effects as a neuromodulator upon plasticity, arousal and reward. ACh has an important role in the enhancement of sensory perceptions when we wake up and in sustaining attention.
ACh has also been shown to promote REM sleep
Слайд 67
Research, Use, & Age
>6 months –diazepam (Valium), chlorpromazine
(Thorazine)
>2 yrs –Valproate (Depakene), lamotrigine (Lamictal) (for seizures)
>3 yrs
– hydroxyzine (Atarax), dextroamphetamine (Dexedrine)
>5yrs- imipramine (Tofranil) (for enuresis)
>5 yrs –risperidone (Risperdal), autistic disorder with irritability
>6 yrs – atomxetine (Strattera), methylphenidate (Ritalin), sertraline (Zoloft)
Слайд 68
Research, Use, & Age (cont)
>7yrs- fluoxetine (Prozac)
>8yrs- fluvoxamine
(Luvox)
>10 yrs –risperidone, bipolar mania
>13 yrs-risperidone, Schizophrenia
>12 yrs old
– thiothixene (Navane), molindone (Moban), perphenazine (Trilafon), Clonidine (Catapres), Lithium, lorazepam (Ativan), amitryptilline (Elavil)
Unspecified – thioridazine (Mellaril), trifluoperazine (Stelazine), carbamazepine (Tegretol)
Слайд 69
Mood, emotion,
cognitive function
Motivation
Sex
Appetite
Aggression
Anxiety
Irritability
Energy
Interest
Impulsivity
Drive
Norepinephrine
Serotonin
Dopamine
Several Neurotransmitters Are Involved in
Regulating Mood
Stahl SM. Essential Psychopharmacology: Neuroscientific Basis and Practical
Applications. 2nd ed. Cambridge, UK: Cambridge University Press; 2000:152.
Слайд 70
Gamma-aminobutyric acid (GABA)
GABA is the main inhibitory neurotransmitter
in the central nervous system (CNS). GABAergic inhibition is
seen at all levels of the CNS, including the hypothalamus, hippocampus, cerebral cortex and cerebellar cortex. As well as the large well-established GABA pathways, GABA interneurons are abundant in the brain, with 50% of the inhibitory synapses in the brain being GABA mediated.
Слайд 71
Antianxiety Agents
GABA receptors
Valium (diazepam)
Ativan (lorazepam)
Klonopin (clonazepam)
Xanax (alprazolam)
Слайд 72
Antianxiety Agents (cont)
Valium/Ativan/Klonopin/Xanax
Clumsiness
Sleepiness
Dizziness
Irritability
Unsteadiness
Confusion
Problems with memory
Слайд 73
Serotonin (5-HT)
The principal centers for serotonergic neurons are
the rostral and caudal raphe nuclei. From the rostral
raphe nuclei axons ascend to the cerebral cortex, limbic regions and specifically to the basal ganglia. Serotonergic nuclei in the brain stem give rise to descending axons, some of which terminate in the medulla, while others descend the spinal cord.
Слайд 74
Antianxiety Agents (cont)
5HT Receptors
Buspar (buspirone)
MISC (MOA unknown)
Atarax
(hydroxizine HCl)
Vistaril (hydroxizine pamoate)
Слайд 75
Antianxiety Agents (cont)
5HT
Buspar
Confusion, Dizziness, Disinhibition, Drowsiness
MISC
Atarax/Vistaril
Cognitive Impairments,
Sedation, Blurred Vision
Слайд 76
Norepinephrine (NE)
Many regions of the brain are supplied
by the noradrenergic systems. The principal centers for noradrenergic
neurons are the locus coeruleus and the caudal raphe nuclei. The ascending nerves of the locus coeruleus project to the frontal cortex, thalamus, hypothalamus and limbic system. Noradrenaline is also transmitted from the locus coeruleus to the cerebellum. Nerves projecting from the caudal raphe nuclei ascend to the amygdala and descend to the midbrain.
Слайд 77
Serotonin (5-HT)
The principal centers for serotonergic neurons are
the rostral and caudal raphe nuclei. From the rostral
raphe nuclei axons ascend to the cerebral cortex, limbic regions and specifically to the basal ganglia. Serotonergic nuclei in the brain stem give rise to descending axons, some of which terminate in the medulla, while others descend the spinal cord.
Слайд 78
Antidepressants
TCA (NE and/or 5HT reuptake presynaptic)
Elavil (amitriptyline)
Asendin (amoxapine)
Anafranil (clomipramine)
Norpramin (desipramine)
Sinequan (doxepin)
Tofranil
(imipramine)
Pamelor/Aventyl (nortriptyline)
Vivactil (protriptyline)
Surmontil (trimipramine)
Слайд 79
Antidepressants (cont)
TCA
Elavil/Tofranil/Pamelor
Fatigue
Drowsiness/Insomnia
Mild Tremors
Nightmares
Restlessness
Confusion
Слайд 80
Serotonin (5-HT)
The principal centers for serotonergic neurons are
the rostral and caudal raphe nuclei. From the rostral
raphe nuclei axons ascend to the cerebral cortex, limbic regions and specifically to the basal ganglia. Serotonergic nuclei in the brain stem give rise to descending axons, some of which terminate in the medulla, while others descend the spinal cord.
Слайд 81
Antidepressants (cont)
SSRI (selective seratonin reuptake inhibitors)
Celexa (citalopram)
Lexapro (escitalopram)
Prozac/Sarafem
(fluoxetine)
Paxil (paroxetine)
Zoloft (sertraline)
Luvox (fluvoxamine)
Viibryd (vilazodone)
Слайд 82
Antidepressants (cont)
SSRI
Celexa/Prozac/Paxil/Zoloft/Lexapro/Viibryd
Agitation
Nervousness
Fatigue
Sleep Problems
Vertigo
Sexual Side Effects
Слайд 83
Antidepressants (cont)
MAOI (monoamine oxidase inhibitors)
Nardil (phenelzine)
Parnate (tranylcypromine)
Marplan (isocarbozide)
Слайд 84
Antidepressants (cont)
MAOI
Nardil/Parnate/Marplan
Dizziness
Headache
Sleep Problems
Слайд 85
Norepinephrine (NE)
Many regions of the brain are supplied
by the noradrenergic systems. The principal centers for noradrenergic
neurons are the locus coeruleus and the caudal raphe nuclei. The ascending nerves of the locus coeruleus project to the frontal cortex, thalamus, hypothalamus and limbic system. Noradrenaline is also transmitted from the locus coeruleus to the cerebellum. Nerves projecting from the caudal raphe nuclei ascend to the amygdala and descend to the midbrain.
Слайд 86
Serotonin (5-HT)
The principal centers for serotonergic neurons are
the rostral and caudal raphe nuclei. From the rostral
raphe nuclei axons ascend to the cerebral cortex, limbic regions and specifically to the basal ganglia. Serotonergic nuclei in the brain stem give rise to descending axons, some of which terminate in the medulla, while others descend the spinal cord.
Слайд 87
Antidepressants (cont)
MISC (MOA unclear)
Desyrel (trazodone)
Wellbutrin/Zyban (bupropion)
Effexor (venlafaxine)
Serzone (nefazodone)
Cymbalta
(duloxetine)
Pristiq (desvenlafaxine)
Remeron (mirtazepine)
Слайд 88
Antidepressants (cont)
MISC
Desyrel/Wellbutrin/Effexor/Serzone/Cymbalta/
Pristiq/Remeron
Agitation
Drowsiness
Sleep Disturbance
Strange Dreams
Increased Blood Pressure
Слайд 89
,
Intake
Gathering Information
Initial Treatment Plan
Слайд 90
Gathering Information
The Initial Play Therapy Session
Observation: Medication Symptoms/Impact
Behavioral
Changes
Cognitive Changes
Emotional Changes
Слайд 91
Intake
Past medications: List, in chronological order, all psychotropic
medications the individual took in the past. If the
list is long, print it separately and bring it to your appointment.
Age Medication Name Dose Comments
____ _____________ ________ ______________________ ____ _____________ ________ ______________________ ____ _____________ ________ ______________________
____ _____________ ________ ______________________
Слайд 92
Intake
Current medications: List, in chronological order, all psychotropic
medications the individual is currently taking. Don’t forget about
over-the counter medications.
Age Medication Name Dose Comments
____ _____________ ________ ______________________ ____ _____________ ________ ______________________ ____ _____________ ________ ______________________
____ _____________ ________ ______________________
Слайд 93
Medication/Behavioral/Cognitive/Emotional/Developmental
Time Line
Слайд 94
The Initial Treatment Plan
How will you address medication
side effect(s) as part of the therapeutic process?
Can you
link a skill/activity/technique to a side effect and reduce its impact on therapy?
What can you do to accomplish side effect reduction as well as therapeutic progress?
Слайд 96
Addressing Medication Side Effects in the Treatment Plan
4
Presentation Types, Each Requires Something Different
The Warm Up
The Cool
Down
The Warm Up-Cool Down
The Cool Down-Cool Down
Слайд 97
Left and Right Brain
LEFT BRAIN FUNCTIONS
uses logic
detail oriented
facts
rule
words and language
present and past
math and science
can comprehend
knowing
acknowledges
order/pattern perception
knows
object name
reality based
forms strategies
practical
safe
RIGHT BRAIN FUNCTIONS
uses feeling
"big picture" oriented
imagination rules
symbols and images
present and future
philosophy & religion
can "get it" (i.e. meaning)
believes
appreciates
spatial perception
knows object function
fantasy based
presents possibilities
impetuous
risk taking
Слайд 98
Working with Lethargy in Play Therapy
Slow Down
Experiential Activities
Arts
and Crafts
Слайд 99
Working with Lethargy in Play Therapy (cont)
If you
have an outdoor space:
Consider the benefits of “fresh air
and natural sunlight”
Walks
Hop Scotch
Swinging
Слайд 100
Dopamine (DA)
Dopamine is transmitted via three major pathways.
The first extends from the substantia nigra to the
caudate nucleus-putamen (neostriatum) and is concerned with sensory stimuli and movement. The second pathway projects from the ventral tegmentum to the mesolimbic forebrain and is thought to be associated with cognitive, reward and emotional behavior. The third pathway, known as the tubero-infundibular system, is concerned with neuronal control of the hypothalmic-pituatory endocrine system.
Слайд 101
Antipsychotics
Phenothiazine Derv. (DA receptor antagonist)
Thorazine (Chlorpromazine)
Prolixin (fluphenazine)
Serentil (mesoridazine)
Trilafon
(perphenazine)
Compazine (prochlorperazine)
Stelazine (trifluoperazine)
Mellaril (thioridazine)
Слайд 102
Antipsychotics (cont)
Phenothiazine derv.
Thorazine/Stelazine/Mellaril
Akathisia
Akinesia
Sleepiness
Cognitive Blunting
Stiffness
Слайд 103
Antipsychotics (cont)
Phenylbutylpiperadine derv.
Haldol (haloperidol)
Orap (pimozide)
Слайд 104
Antipsychotics (cont)
Phenylbutylpiperadine derv.
Haldol/Orap
Akathisia
Akinesia
Blurred Vision
Sleepiness
Cognitive Blunting
Слайд 105
Dopamine (DA)
Dopamine is transmitted via three major pathways.
The first extends from the substantia nigra to the
caudate nucleus-putamen (neostriatum) and is concerned with sensory stimuli and movement. The second pathway projects from the ventral tegmentum to the mesolimbic forebrain and is thought to be associated with cognitive, reward and emotional behavior. The third pathway, known as the tubero-infundibular system, is concerned with neuronal control of the hypothalmic-pituatory endocrine system.
Слайд 106
Serotonin (5-HT)
The principal centers for serotonergic neurons are
the rostral and caudal raphe nuclei. From the rostral
raphe nuclei axons ascend to the cerebral cortex, limbic regions and specifically to the basal ganglia. Serotonergic nuclei in the brain stem give rise to descending axons, some of which terminate in the medulla, while others descend the spinal cord.
Слайд 107
Glutamate
In the normal brain the prominent glutamatergic pathways
are: the cortico-cortical pathways; the pathways between the thalamus
and the cortex; and the extrapyramidal pathway (the projections between the cortex and striatum). Other glutamate projections exist between the cortex, substantia nigra, subthalmic nucleus and pallidum. Glutamate-containing neuronal terminals are ubiquitous in the central nervous system and their importance in mental activity and neurotransmission is considerable.
Слайд 108
Acetylcholine (Ach)
There are three Acetylcholine pathways in the
CNS. (a) The Pons to thalamus and cortex, (b)
Magnocellular forebrain nucleus to cortex, & (c) Septohippocampal. In the central nervous system, ACh has a variety of effects as a neuromodulator upon plasticity, arousal and reward. ACh has an important role in the enhancement of sensory perceptions when we wake up and in sustaining attention.
ACh has also been shown to promote REM sleep
Слайд 110
Antipsychotics (cont)
Dibenzapine derv.
Loxitane (loxapine)
Zyprexa (olanzapine)
Seroquel (quetiapine)
Benzisoxazole derv.
Risperdal (risperidone)
Слайд 111
Antipsychotics (cont)
Dibenzapine derv.
Loxitane/Zyprexa/Seroquel
Sedation
Cognitive Blunting
Benzisoxazole derv.
Risperdal
Drowsiness, Dizziness, Cognitive Blunting,
Movement Disorders
Слайд 112
Antipsychotics (cont)
Dihydroindolones
Geodone (ziprasidone)
Moban (molindone)
Quinolinone
Abilify (aripiprazole)
Benzoisothiazol derv.
Latuda
(lurasidone)
MISC
Eskalith/Lithobid (lithium)
Слайд 113
Antipsychotics (cont)
Dihydroindolones
Geodone/Moban
Sleepiness
Confusion
Quinolinone
Abilify
Confusion
Benzoisothiazol derivatives
Latuda (lurasidone)
Drowsiness
An internal restless or
jittery feeling (akathisia)
Movement or muscle disorders
Insomnia
MISC
Lithium
Tremors
Слайд 114
Working With Cognitive Cloudiness in Play Therapy
Slow Down
Consider
the benefits of “fresh air and natural sunlight”
Слайд 115
Working With Cognitive Cloudiness in Play Therapy (cont)
Simple
Games (still require an attempt to focus)
Matching Games
Card Games
Слайд 116
Working With Cognitive Cloudiness in Play Therapy (cont)
Puzzles
Mazes
Guessing
Games
Hangman
Слайд 117
Working With Emotional Blunting in Play Therapy
Rhythm
Music
Dance
Bibliotherapy
Слайд 118
Working With Emotional Blunting in Play Therapy (cont)
Emotions
Tic Tac Toe
Emotions Identification
Emotion Cards—identification and act out
Facial Expressions
Слайд 119
Working With Emotional Blunting in Play Therapy (cont)
Art—Guided
or Abstract
Jokes
Cartoons
Слайд 120
Working with Coordination Difficulties in Play Therapy
Practice
Use Rhythm
Increase
speed/intensity
Слайд 121
Gross Motor Skills
Involve the following in Play Therapy:
Crafts
Finger
Paints
Hula Hoops
Слайд 122
Gross Motor Skills (cont)
Involve the following in Play
Therapy:
Things that can be manipulated, stacked, etc. but are
larger.
Legos
Blocks
Dominos
Marbles
Jenga
Слайд 123
Fine Motor Skills
Involve the following in Play Therapy:
Things
that can be manipulated, stacked, etc. but are smaller.
Pick
up Sticks
Tiddlywinks
The game “Operation”
Ring Toss Games
Fishing Games
Слайд 124
Fine Motor Skills (cont)
Crafts which include:
Beads
Macaroni/Shaped Pasta
Слайд 125
Other Things
Consult or get to know an
Occupational Therapist
Слайд 126
Dopamine (DA)
Dopamine is transmitted via three major pathways.
The first extends from the substantia nigra to the
caudate nucleus-putamen (neostriatum) and is concerned with sensory stimuli and movement. The second pathway projects from the ventral tegmentum to the mesolimbic forebrain and is thought to be associated with cognitive, reward and emotional behavior. The third pathway, known as the tubero-infundibular system, is concerned with neuronal control of the hypothalmic-pituatory endocrine system.
Слайд 127
CNS Stimulants
Analeptic
Provigil (modafinil)
Amphetamines
Dexedrine
(dextroamphetamine)
Desoxyn (methamphetamine)
Adderall (amphetamine mixture)
Vyvanse (lisdexamfetamine)
Слайд 128
CNS Stimulants (cont)
Analeptic
Provigil
Irritability
Amphetamines
Adderall/Dexedrine/Desoxyn/Vyvanse
Agitation/Aggression
Sleep Problems
Nervousness
Restlessness
Adderall more likely to
create some mood lability and irritability than the other
stimulant medications.
Слайд 129
CNS Stimulants (cont)
Non-Amphetamines
Ritalin/Concerta/Metadate/Methylin (methylphenidate)
Cylert (pemoline)
Focalin (dexmethylphenidate)
Daytrana (methylphenidate)---Patch
Слайд 130
CNS Stimulants (cont)
Non-Amphetamines
Ritalin/Concerta/Daytrana/Metadate/Methylin
Sleep Problems
Nervousness
Agitation/Aggression
Cylert
Insomnia
Depression
Irritability
Focalin
Nervousness
Sleep Problems
Слайд 131
Norepinephrine (NE)
Many regions of the brain are supplied
by the noradrenergic systems. The principal centers for noradrenergic
neurons are the locus coeruleus and the caudal raphe nuclei. The ascending nerves of the locus coeruleus project to the frontal cortex, thalamus, hypothalamus and limbic system. Noradrenaline is also transmitted from the locus coeruleus to the cerebellum. Nerves projecting from the caudal raphe nuclei ascend to the amygdala and descend to the midbrain.
Слайд 132
MISC ADHD Medications
Strattera (atomoxetine) potent inhibitor of presynaptic
NE transporter
Слайд 133
MISC ADHD Medications (cont)
Strattera
Fatigue
Sleep Disturbance
Слайд 134
Working with Agitation/Aggression in Play Therapy
Sandtray or Sand
Play
Clay Therapy (Paul White)
Bibliotherapy
Слайд 135
Working with Agitation/Aggresion in Play Therapy (cont)
Consider the
benefits of “fresh and Natural sun light”
Rhythm
Music
Natural Sounds
Слайд 136
Gamma-aminobutyric acid (GABA)
GABA is the main inhibitory neurotransmitter
in the central nervous system (CNS). GABAergic inhibition is
seen at all levels of the CNS, including the hypothalamus, hippocampus, cerebral cortex and cerebellar cortex. As well as the large well-established GABA pathways, GABA interneurons are abundant in the brain, with 50% of the inhibitory synapses in the brain being GABA mediated.
Слайд 137
Sedative/Hypnotics
(GABA)
Newer
Ambien (zolpidem)
ProSom (estazolam)
Lunesta (eszopiclone)
Sonata (zaleplon)
Older
Halcion (triazolam)
Restoril (temazepam)
Слайд 138
Sedative/Hypnotics (cont)
GABA
Ambien/Prosom/Lunesta/Sonata/Halcion/Restoril
Fatigue
Clumsiness
Слайд 139
Sedative/Hypnotics (cont)
Melatonin
Rozerem (ramelteon)
Fatigue
Clumsiness
Слайд 140
Gamma-aminobutyric acid (GABA)
GABA is the main inhibitory neurotransmitter
in the central nervous system (CNS). GABAergic inhibition is
seen at all levels of the CNS, including the hypothalamus, hippocampus, cerebral cortex and cerebellar cortex. As well as the large well-established GABA pathways, GABA interneurons are abundant in the brain, with 50% of the inhibitory synapses in the brain being GABA mediated.
Слайд 141
Anticonvulsants/Psychiatric Uses
Tegretol/Carbatrol (carbamazepine)
Trileptal (oxcarbazepine)
Neurontin (gabapentin)
Topamax (topiramate)
Depakote/Depakene (valproic acid)
Lamictal
(lamotrigine)
Gabitril (tiagabine)
Слайд 142
Anticonvulsants/Psychiatric Uses (cont)
Tegretol/Carbatrol
Dizziness, Drowsiness, Blurred Vision
Trileptal/Neurontin/Topamax/Lamictal
Fatigue, Dizziness, Nervousness
Depakote/Depakene
Drowsiness,
Lethargy
Gabitril
Fatigue, dizziness, unstable walking, seizures
Слайд 143
Acetylcholine (Ach)
There are three Acetylcholine pathways in the
CNS. (a) The Pons to thalamus and cortex, (b)
Magnocellular forebrain nucleus to cortex, & (c) Septohippocampal. In the central nervous system, ACh has a variety of effects as a neuromodulator upon plasticity, arousal and reward. ACh has an important role in the enhancement of sensory perceptions when we wake up and in sustaining attention.
ACh has also been shown to promote REM sleep
Слайд 144
Antiparkinsons/Psychiatric Uses
Cogentin (bentropine)
Artane (trihexyphenidyl)
No major negative effects
Слайд 145
MISC MISC MISC/Psychiatric Uses
Benadryl (diphenhyramine)—with older Antipsychotics
Inversine (mecamylamine)---Tourette’s
Revia
(naltrexone)---Severe Behavioral Disorder in MR, Pervasive Developmental Disorders
Слайд 146
MISC MISC MISC Psychiatric Uses (cont)
Benadryl
Sedation, Cognitive
Impairments
Слайд 148
Norepinephrine (NE)
Many regions of the brain are supplied
by the noradrenergic systems. The principal centers for noradrenergic
neurons are the locus coeruleus and the caudal raphe nuclei. The ascending nerves of the locus coeruleus project to the frontal cortex, thalamus, hypothalamus and limbic system. Noradrenaline is also transmitted from the locus coeruleus to the cerebellum. Nerves projecting from the caudal raphe nuclei ascend to the amygdala and descend to the midbrain.
Слайд 149
MISC MISC MISC/Psychiatric Uses
Inderal (propranolol)---IED, PTSD
Catapres (clonidine)—ADHD, Conduct
Disorder, Tourette’s
Tenex/Intuniv (guanfacine)---ADHD, Tourette’s
Irritability, Tiredness, Hypotension
Слайд 150
Antihypetensives
Inderal (propranolol)
Drowsiness, Hypotension
Catapres (clonidine)
Sedation, Drowsiness, Depression, Irritability,
Hypotension
Tenex/Intuniv
(guanfacine)
Irritability, Tiredness, Hypotension
Слайд 151
Items We Should All Have: They Accomplish Multiple
Tasks
Cards
Marbles
Jacks
Dominos
Clay
Sand
Слайд 152
Games We Should All Have: They Accomplish Multiple
Tasks
Jenga
Pick-up-Sticks
Connect 4
Tic Tac Toe
Operation
Chutes and Ladders
Слайд 153
Conclusion
Remember:
The goal is to go slow and be
supportive. Allow the child to push past the side
effect.
When stimulated the brain/body can overcome/compensate for medication side effects.
Слайд 154
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