CanFASD: Transforming FASD Treatment

In honour of FASD Month,CanFASD wants to share some of the research projects they have on the go that are bringing together people and organizations with unique strengths to come up with effective solutions. Today’s feature is the Psychotropic Medication Algorithm for Fetal Alcohol Spectrum Disorder.

Medication for People with FASD

Medication can often help reduce or eliminate some of the symptoms that a person is experiencing. However, up until the development of this resource, clinicians had no guidelines to help them make decisions about what medication they should give people with FASD or neurobehavioral disorders. As a result, families reported that people with FASD were often being prescribed too many medications and those medications often didn’t work as expected.

Families and clinicians alike were calling for solutions to ensure people with FASD receive the appropriate medication. In response, researchers at CanFASD, in partnership with other organizations came up with the Psychotropic Medication Algorithm.

What is the Psychotropic Medication Algorithm?

The Psychotropic Medication Algorithm was developed to guide clinicians as they see patients with FASD and Neurobehavioural Disorders associated with Prenatal Alcohol Exposure (ND-PAE).

The medication algorithm is a step-by-step instruction manual that helps clinicians make decisions about what medications to give a patient with FASD/ND-PAE. It is the first-ever treatment recommendation for this population.

Since its launch in 2018, the medication algorithm has been one of our most successful resources. We’ve heard anecdotally from clinicians at the Canadian Paediatric Society conference that they use and recommend this resource regularly in their practice. It was the most downloaded resource on our website last year and is consistently one of our top five most viewed webpages. We’ve heard from families about its use, one individual citing it as an enormous success that stopped aggression in their household.

How did this project come about?

Some families and caregivers through CanFASD’s Family Advisory Committee (FAC) shared their concerned about the use of medication among their loved ones. Dr. Mansfield Mela, CanFASD’s Diagnostic Co-Lead and his team worked with the FAC to put together a group of experts, mainly north American and those experts come from FASD and non-FASD professions. The group met 4 times to review the literature and shared our experiences related to the topic.

Dr. Mela and a team of 12 multidisciplinary international experts spent over two years developing the decision-tree style medication algorithm. First, the team did a review of all the research literature on FASD and psychiatric medication. They summarized the results and gave them to a panel of experts to review.

The expert panel was led by a family member of an individual with FASD and consisted of top experts who had experience working with patients with FASD, including physicians from psychiatry, pediatrics, and family medicine. Alongside, these experts were an algorithm developer, pharmacologist, and research coordinator. Together, they created the medication algorithm.

Evaluation of the Psychotropic Medication Algorithm for Fetal Alcohol Spectrum Disorder

Dr. Mela and a team of 12 multidisciplinary international experts 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

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